Abstract
Objective Hypertensive disorders of pregnancy, defined as chronic (<20 weeks) or gestational
(>20 weeks), are a leading cause of pregnancy-related mortality in the United States.
Hypertensive disorders of pregnancy had increased prevalence from 13.3 to 15.9% among
delivery hospitalizations between 2017 and 2019. The objective of this project was
to increase the percentage of obstetric patients with hypertensive emergency who received
evidence-based treatment within 60 minutes at a single academic center.
Study Design Data were collected before and after the implementation of a hypertension patient
safety bundle. Each occurrence of hypertensive emergency was assessed to determine
if evidence-based intervention occurred within 60 minutes, and if the intervention
steps were successfully followed. Bundle implementation included creation of a standardized
order set and interdisciplinary team-based simulations. Baseline data compared 250
preimplementation to 250 postimplementation interventions. The quality improvement
interdisciplinary team reevaluated data monthly and incorporated process improvements
through Plan-Do-Study-Act (PDSA) cycles to achieve a goal of 80% of patients receiving
evidence-based treatment within 60 minutes.
Results A total of 1,025 hypertensive emergencies were identified in 543 patients. Prior
to the protocol on average 64% of patients received evidence-based, timely treatment.
After implementation of this bundle and several PDSA cycles, we sustained >80% of
patients receiving target treatment for the final 6 months of data collection. The
leading deviations were “no medication given” and “incorrect medication.” Improvements
in order set accessibility and repeated team-based trainings led to improvement in
these identified protocol deviations.
Conclusion Implementation of a patient safety bundle led to a sustained 6-month improvement
in the percentage of patients receiving appropriate treatment of obstetric hypertensive
emergency within 60 minutes of the first severe hypertension measurement. Processes
that may have helped achieve this outcome included standardized order sets, team awareness
of institutional data, and team-based simulations.
Key Points
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Hypertensive emergency treatment improved with patient safety bundle.
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Training and order sets improved adherence to hypertensive emergency patient safety
bundle.
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Regular data review necessary for sustainability of hypertensive emergency patient
safety bundle.
Keywords
maternal morbidity and mortality - obstetric hypertension - hypertensive emergency
- patient safety bundle
