As part of the Health Resources Service Administration (HRSA) funded Maternal Health Innovations (MHI) Grant to reduce NC’s Maternal Mortality and Morbidity, the Provider Support Network is building partnerships and responding to identified needs of the providers in Perinatal Region IV. Through conversations with outpatient clinics, it came to our attention that many clinics do not have the resources or systems in place to quickly respond to patients with severe hypertension.
The national maternal safety bundles have primarily been focused on the inpatient setting. We have drafted an “Outpatient Severe Hypertension Bundle.” It consists of an adapted version of the AIM ACOG “Severe Hypertension in Pregnancy and Postpartum Bundle” (with the addition of a fifth “R” – “Respectful Care”).
Take a look at the Alliance for Innovation on Maternal Health Inpatient Severe Hypertension Bundle
Review The California Maternal Quality Care Collaborative Comprehensive In-patient Toolkit
Every Clinic:
- Standards in place: early warning signs (1), diagnostic criteria (2), monitoring and treatment of severe preeclampsia.
- Process for timely triage and evaluation of pregnant or postpartum patient who calls or presents to clinic with hypertension of signs/symptoms of preeclampsia.
- Standards for educating prenatal and postpartum patients and support persons on early warning signs and how to get help, including printed materials.
- Role specific provider and staff education protocols, including proper blood pressure measurement (including BP cuff size, proper patient positioning, and timing).
- Rapid access to medication used for treatment of severe hypertension.
- Plan for escalation, obtaining appropriate consultation, and maternal transport (algorithm).
- Clinic based drills with post drill debriefs of severe hypertension.
Readiness Resources:
ACOG Practice Bulletin 2020 Gestation and Hypertension
ACOG Hypertension Bundle (slide 29)
Outpatient-Severe-Hypertension-Evaluation-and-Management
CDC Hear Her Warning Signs Poster
safehealthcareforeverywoman 2015_Safety Action Series
SMI-hypertension-bundle-oral-nifedipine] (page 10)
Every Patient:
- Standard protocol for proper blood pressure measurement and assessment for all pregnant and postpartum patients, including home blood pressure monitor if indicated.
- Standard response to maternal early warning signs including listening to and investigating patient symptoms and assessment of labs when appropriate (e.g. CBC with platelets, AST and ALT, urine protein).
- Patient and support person education, including culturally appropriate resources and printed materials, on early warning signs of severe hypertension/pre-eclampsia and how to get help.
- Convene diverse patient focus groups to learn how patients learn best.
Recognition & Prevention Resources:
https://www.communitycarenc.org/home-blood-pressure-monitoring-for-patients
https://www.heart.org/-/media/files/health-topics/high-blood-pressure/my-blood-pressure-log.pdf
https://www.cdc.gov/hearher/partners-friends-family/index.html
https://safehealthcareforeverywoman.org/wp-content/uploads/MEWS-Protocol.pdf
Every Case of Severe Hypertension:
- Clinic-wide standard protocols with checklists and escalation policies for management and treatment of:
- Severe hypertension/pre-eclampsia/eclampsia during pregnancy
- Postpartum presentation of severe hypertension/pre-eclampsia/eclampsia
- Minimum Requirements for Protocol
- Notification of provider if systolic BP =/> 160 and/or diastolic BP =/> 110 (severe range) and retake in 15 minutes
- After the second severe range BP, treatment with oral Nifedipine IR (10 mg) should be initiated ASAP (within 60 minutes of verification)
- Escalation and care transition
- Maternal transport (algorithm) [Clinic Specific].
Response Resources:
Outpatient Severe Hypertension Evaluation and Management
New onset postpartum hypertension.pdf
acog.org/smi-hypertension-bundle-slides.pdf (Slide 29)
Every Clinic:
- Establish a culture of huddles for patients with severe hypertension/preeclampsia (include the patient and support person).
- Rehearsed pathway for maternal transport to the hospital.
- Post transfer debrief with your team to identify successes and opportunities.
- Multidisciplinary review of all severe hypertension/pre-eclampsia cases transferred to the hospital for systems and communications issues, including attention to care transitions and continuity of care.
- Monitor outcomes and process metrics
- Monitor process and outcome data stratified by race and ethnicity
Reporting Systems/Learning Resources:
https://www.mombaby.org/wp-content/uploads/2021/07/Debrief-Outpatient-HTN-Bundle-form-1-1.docx
Every Patient/Every Clinic:
- Ensure all educational resources and printed materials are appropriate for the patient’s health literacy, cultural needs and language proficiency.
- Assess patient and support person’s understanding of the urgency of timely treatment of severe hypertension and escalation of care.
- Assess the structural and social drivers of health and provide linkage to available resources.
- Acknowledge patient’s concerns and assist with overcoming obstacles to going to the hospital (e.g. childcare, financial stress, past hospital-related trauma, etc.).
- Acknowledge and assist with overcoming barriers to the care plan (medication, appointments, antenatal testing).
- Collaborate with the hospital, outpatient provider, state agencies, and community groups to maintain a set of referral resources for social determinant needs.
- Implement strategies to mitigate racial/ethnic disparities identified through data collected.
- Establish a mechanism for patients, families, and staff to report inequitable care and episodes of miscommunication or disrespect
- Establish systems to accurately document self-identified race, ethnicity, and primary language.
- Provide staff-wide education on:
- Peripartum racial and ethnic disparities and their root causes
- Best practices for shared decision making
- Implicit bias training
- Shared Decision Making: https://www.dartmouth-hitchcock.org/patients-visitors/decision-making-help
- Implicit Bias Training: https://thinkculturalhealth.hhs.gov/education/maternal-health-care
- Maternal Health and Learning Innovation Resource Center: https://maternalhealthlearning.org/resources/
Outpatient Hypertension Management Practice Bulletin can be downloaded and viewed here.
Hypertension Practice Bulletin Resources References:
- MSc JEM, Mph AVM, Pettker CM, Simhan AH. Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222. American College of Obstetricians and Gynecologists. 2020 Jun 6;135(6): e237–60.
- Paul G. Schmitz TN. Hypertension, Clinical Updates in Women’s Health Care. American College of Obstetrics and Gynecology. 2016
- AIM PATIENT SAFETY BUNDLES [Internet]. ALLIANCE FOR INNOVATION ON MATERNAL HEALTH. 2021. Available from: https://saferbirth.org/psbs/severe-hypertension-in-pregnancy/
- Pregnancy Mortality Surveillance System [Internet]. CDC Centers for Disease Control and Prevention. 2022. Available from:https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Freproductivehealth%2Fmaternalinfanthealth%2Fpregnancy-mortality-surveillance-system.htm
- Howell E et al. Reduction of Peripartum Racial and Ethnic Disparities: A Conceptual Framework and Maternal Safety Consensus Bundle. Journal of Midwifery & Women’s Health. 2019 May;63(3):353.
- HEAR HER Campaign [Internet]. CDC Centers for Disease Control and Prevention. 2022. Available from: https://www.cdc.gov/hearher/index.html
- California Collaborative on District Reform. Available from:https://cacollaborative.org/
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of an award totaling $10,216,885 with 0% percentage financed with non-governmental sources. The contents of those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS or the U.S. Government.” HRSA-funded. (C) 2020.
Please contact Liz Soto at lizso@med.unc.edu for more information
