Challenge 11B

Pre-eclampsia

Executive Summary Checklist

Complications arising from hypertensive disorders of pregnancy are among the leading causes of severe maternal morbidity and preventable maternal mortality. This maternity patient safety topic was selected by the National Partnership for Maternal Safety for priority development and national implementation. This safety bundle outlines critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women’s Health Care. The hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources to assist with implementation.1

Readiness Across Every Unit

  • Adopt standards for early warning signs, diagnostic criteria, monitoring and treatment of severe preeclampsia/eclampsia (include order sets and algorithms)2,3,4,5,6
  • Unit education on protocols, unit-based drills (with post-drill debriefs)2,3,4
  • Process for timely triage and evaluation of pregnant and postpartum women with hypertension including ED and outpatient areas2,3,4,5,6
  • Rapid access to medications used for severe hypertension/eclampsia: Medications should be stocked and immediately available on L&D and in other areas where patients may be treated. Include brief guide for administration and dosage.2,3,4
  • System plan for escalation, obtaining appropriate consultation, and maternal transport, as needed2,3,4,5

Recognition

  • Adoption of a standard protocol for measurement and assessment of BP and urine protein for all pregnant and postpartum women4,6
  • Implementation of standard response to maternal early warning signs including listening to and investigating patient symptoms and assessment of labs (e.g. CBC with platelets, AST and ALT)4,6
  • Implementation of facility-wide standards for educating prenatal and postpartum women on signs and symptoms of hypertension and preeclampsia4,6

Response

  • Facility-wide standard protocols with checklists and escalation policies for management and treatment of:4,6
    • Severe hypertension
    • Eclampsia, seizure prophylaxis, and magnesium over-dosage
    • Postpartum presentation of severe hypertension/preeclampsia
  • Minimum requirements for protocol:4,6
    • Notification of physician or primary care provider if systolic BP ≥ 160 or diastolic BP ≥ 110 for two measurements within 15 minutes
    • After the second elevated reading, treatment should be initiated ASAP (preferably within 60 minutes of verification)
    • Includes onset and duration of magnesium sulfate therapy
    • Includes escalation measures for those unresponsive to standard treatment
    • Describes manner and verification of follow-up within 7 to 14 days postpartum
    • Describe postpartum patient education for women with preeclampsia
  • Support plan for patients, families, and staff for ICU admissions and serious complications of severe hypertension4

Reporting/Learning in Every Unit

  • Establish a culture of huddles for high risk patients and post-event debriefs to identify successes and opportunities4
  • Multidisciplinary review of all severe hypertension/eclampsia cases admitted to ICU for systems issues
  • Monitor outcomes and process metrics4,7
    • Adherence to protocols for acute management
    • Appropriateness of response to early warning criteria
    • Documentation of education of pregnant and postpartum women about symptoms of preeclampsia for women at risk
    • Occurrence of post severe maternal morbidity (SMM) event debrief and outcomes
    • Timeliness of medication administration
  • Timeliness of triage and evaluation4

Between the 2017 World Patient Safety, Science & Technology Summit and the 2017 Midyear Planning Meeting a workgroup comprised of experts representing administrators, clinicians, technologists and patient advocates will meet to update this APSS. If you are interested in joining this workgroup, please email us.

References
  1. Council on Patient Safety | Women & Mothers’ Health Care. (n.d.). Retrieved from http://www.safehealthcareforeverywoman.org
  2. The American Congress of Obstetricians and Gynecologists. (n.d.). Preeclampsia and hypertension in pregnancy: Resource overview. Retrieved from: http://www.acog.org/Womens-Health/Preeclampsia-and-Hypertension-in-Pregnancy
  3. Committee on Obstetric Practice. (2015). Committee Opinion No. 623: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period. Obstetrics and Gynecology, 125(2), 521.
  4. California Maternal Quality Care Collaborative. Improving Health Care Response to Preeclampsia: A California Quality Improvement Toolkit. Retrieved from: https://www.cmqcc.org/resources-tool-kits/toolkits/preeclampsia-toolkit
  5. American College of Obstetricians and Gynecologists. (2013). Optimizing Protocols in Obstetrics. Key Elements for the Management of Hypertensive Crisis In Pregnancy (In-Patient). Retrieved from: http://www.ilpqc.org/docs/htn/Recognition/ACOGDII(NY)KeyElementsManagementHypertensiveCrisisPregnancy.pdf
  6. New York State Department of Health (2013, May). Hypertensive disorders in pregnancy. Retrieved from: https://www.health.ny.gov/professionals/protocols_and_guidelines/hypertensive_disorders/2013_hdp_guideline_summary. pdf
  7. Council on Patient Safety in Women’s Health Care. (2016). Hypertension Process Metrics Could Include:. Retrieved from: http://safehealthcareforeverywoman.org/wp-content/uploads/2016/09/Reporting-3-Process-Metrics.pdf
  1. Challenge 11: Optimizing Obstetric Safety