Janet H. Muri, MBA; Sandra A. Boyle, BS; and Carolyn Wood, PhD, RN

Health care providers have sought to develop a consensus on the most effective way to manage the care of the pregnant woman with a hypertensive disorder, ultimately improving maternal and neonatal outcomes. Under the direction of the Council on Patient Safety in Women’s Health Care, several organizations involved in women’s health have come together to establish the Alliance for Innovation on Maternal Health (AIM). AIM is a national data-driven maternal safety and quality initiative based on proven implementation approaches. Patient Safety bundles that focus on readiness, recognition & prevention, response, and reporting/systems learning have been developed for some of the major complications of pregnancy impacting maternal morbidity and mortality, including one on hypertension. (2) 

The hypertension bundle review of readiness for every unit includes standardization of protocols for hypertension management, unit education, drills, rapid access to medications and plans to deal with escalation of severe hypertension, including consult and transfer as needed. 

Recognition and prevention for every patient addresses the need for standard protocols for measurement and assessment of B/P and urine protein for all pregnant and postpartum women. Early warning signs and investigation of symptoms with lab assessment should be obtained. Maternal education on signs and symptoms of hypertension and preeclampsia should be part of care for prenatal and postpartum women. 

Response to severe hypertension/preeclampsia is addressed by standard protocols with checklists and escalation policies. Minimum requirements for the protocol outline specific B/P parameters for notification of providers if systolic B/P =/>160 or diastolic B/P =/> 110 for 2 measurements within 15 minutes. After the second elevated reading, treatment should be initiated as soon as possible, preferably within 60 minutes of verification. (3) 

The final component of the bundle, reporting/systems learning, speaks to each unit doing huddles and post-event debriefs, multidisciplinary review of severe cases admitted to ICU and monitoring outcomes and process metrics. 

Findings from the NPIC Special Report 

The Special Report for the period Q4, 2017-Q3, 2018 focused on the review of all delivery cases coded with hypertension at each member hospital in comparison to their peer subgroup and the Perinatal Center Data Base (PCDB) as a whole. Table 1 below displays the average distribution of the seven categories of hypertension cases for NPIC member hospitals. 

Maternal Complications: A profile of maternal co-morbidities/complications for cases coded with hypertension was also included and Table 2 shows the average rate of those complications across all member hospitals in the PCDB. The data shows that longer lengths of stay are fairly common for hypertension cases and 2.7% of all cases are readmitted within 42 days. This is more than twice the postpartum readmission rate (1.1%) for all deliveries at member hospitals. 

Feedback from members also confirmed that a percentage of postpartum readmissions were returning with hypertension diagnoses and had no indication of hypertension during the original delivery discharge. Table 3 below shows that almost 24% of the readmissions within 42 days with a diagnosis of hypertension did not have hypertension coded on their delivery discharge summary. 

Neonatal Complications: More than ninety-six percent (96.2%) of the PCDB mother/baby cases are linked, allowing for the identification of neonatal complications associated with cases coded with maternal hypertension. Table 4 profiles a few of these complications with the largest risk being preterm birth and admission to the special care nursery, both drivers of increased cost and utilization. 

AIM Severe Hypertension in Pregnancy Bundle: Many states and national collaboratives, like NPIC are introducing their hospitals to the Severe Hypertension in Pregnancy Bundle as a way to better identify, respond and manage women with escalating hypertension. In addition to implementing the bundle components with their teams, Severe Maternal Morbidity (SMM) outcome metrics for preeclampsia cases are tracked for each hospital’s baseline period and then quarterly, after initial implementation of the bundle components. 

The denominator for the AIM Severe Maternal Morbidity (SMM) among Preeclampsia Cases outcome measures includes a subset of hypertension codes. Table 5 shows the NPIC Data Base average for both AIM outcome metrics associated with the Severe Hypertension in Pregnancy bundle: the overall rate of SMM among preeclampsia cases and the rate excluding cases with blood transfusion coded as the only severe morbidity. 

NPIC Trends 

The NPIC Trend Data Base icludes hospitals that have been members for the period 2013 – Q3, 2018. For this Special Report, we are focusing on data since the initiation of ICD 10 coding. The analytic period is Q4, 2015-Q3, 2018 (12 quarters). During this period, the Trend Data Base showed a statistically significant increase in all cases coded with hypertension, from 13.5% to 16.7%, a 24% increase in deliveries coded with hypertension. Translating this rate into 1,670 per 10,000 shows a continuing increase over the CDC 2014 rates, a trend of ongoing concern. 

Resources 

1. CDC (2016). Hypertensive Disorders 1993-2014. Retrieved from https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pregnancy. 
2. Severe Hypertension in Pregnancy (+AIM) (2018, October 16). Retrieved from https://safehealthcareforeverywoman.org/patient-safety-bundles/severe-hypertension-in-pregnancy/. 
3. Committee on Obstetric Practice and Society for Maternal–Fetal Medicine. (2018). Low-dose aspirin use during pregnancy. ACOG Committee Opinion No. 743. Obstetrics and Gynecology, 132:e44-66. 

The authors have no relevant disclosures.