Semiautonomous Treatment Algorithm for the Management of Severe Hypertension in Pregnancy

Decreasing ICU and Hospital Length of Stay through a Standardized Respiratory Therapist-driven Electronic Clinical Care Pathway for Status Asthmaticus

Introduction

Status asthmaticus (SA) is a cause of many pediatric hospitalizations. This study sought to evaluate how a standardized asthma care pathway (ACP) in the electronic medical record impacted the length of stay (LOS).

Methods

An interdisciplinary team internally validated a standardized respiratory score for patients admitted with SA to a 25-bed pediatric intensive care unit (PICU) at a tertiary children's hospital. The respiratory score determined weaning schedules for albuterol and steroid therapies. In addition, pharmacy and information technology staff developed an electronic ACP within our electronic medical record system using best practice alerts. These best practice alerts informed staff to initiate the pathway, wean/escalate treatment, transition to oral steroids, transfer level of care, and complete discharge education. The PICU, stepdown ICU (SD ICU), and acute care units implemented the clinical pathway. Pre- and postintervention metrics were assessed using process control charts and compared using Welch's t tests with a significance level of 0.05.

Results

Nine hundred two consecutive patients were analyzed (598 preintervention, 304 postintervention). Order set utilization significantly increased from 68% to 97% (P < 0.001), PICU LOS decreased from 38.4 to 31.1 hours (P = 0.013), and stepdown ICU LOS decreased from 25.7 to 20.9 hours (P = 0.01). Hospital LOS decreased from 59.5 to 50.7 hours (P = 0.003), with cost savings of $1,215,088 for the patient cohort.

Conclusions

Implementing a standardized respiratory therapist-driven ACP for children with SA led to significantly increased order set utilization and decreased ICU and hospital LOS. Leveraging information technology and standardized pathways may improve care quality, outcomes, and costs for other common diagnoses.

Implementation research priorities for addressing the maternal health crisis in the USA: results from a modified Delphi study among researchers

BACKGROUND

Maternal health outcomes in the USA are far worse than in peer nations. Increasing implementation research in maternity care is critical to addressing quality gaps and unwarranted variations in care. Implementation research priorities have not yet been defined or well represented in the plans for maternal health research investments in the USA.

METHODS

This descriptive study used a modified Delphi method to solicit and rank research priorities at the intersection of implementation science and maternal health through two sequential web-based surveys. A purposeful, yet broad sample of researchers with relevant subject matter knowledge was identified through searches of published articles and grant databases. The surveys addressed five implementation research areas in maternal health: (1) practices to prioritize for broader implementation, (2) practices to prioritize for de-implementation, (3) research questions about implementation determinants, (4) research questions about implementation strategies, and (5) research questions about methods/measures.

RESULTS

Of 160 eligible researchers, 82 (51.2%) agreed to participate. Participants were predominantly female (90%) and White (75%). Sixty completed at least one of two surveys. The practices that participants prioritized for broader implementation were improved postpartum care, perinatal and postpartum mood disorder screening and management, and standardized management of hypertensive disorders of pregnancy. For de-implementation, practices believed to be most impactful if removed from or reduced in maternity care were cesarean delivery for low-risk patients and routine discontinuation of all psychiatric medications during pregnancy. The top methodological priorities of participants were improving the extent to which implementation science frameworks and measures address equity and developing approaches for involving patients in implementation research.

CONCLUSIONS

Through a web-based Delphi exercise, we identified implementation research priorities that researchers consider to have the greatest potential to improve the quality of maternity care in the USA. This study also demonstrates the feasibility of using modified Delphi approaches to engage researchers in setting implementation research priorities within a clinical area.

Timely treatment of severe hypertension and risk of severe maternal morbidity at an urban hospital

BACKGROUND

Hypertensive disorders of pregnancy have been identified as a leading contributor to severe maternal morbidity and mortality. Pregnant persons with hypertensive disorders who develop severe hypertension at delivery admission have been shown to experience higher rates of severe maternal morbidity relative to those without severe hypertension. Current guidelines recommend prompt treatment of severe hypertension given known associated maternal and fetal risks; however, only 1 previous study has described an association between timeliness of antihypertensive therapy and risk of severe maternal morbidity.

OBJECTIVE

This study aimed to characterize how development of severe intrapartum hypertension and its timely treatment affect the risk of severe maternal morbidity.

STUDY DESIGN

We conducted a population cohort study of deliveries with and without hypertensive disorders of pregnancy at a single urban hospital between 2016 and 2018. Among deliveries of persons with hypertensive disorders of pregnancy, we identified those with persistent severe hypertension (defined as blood pressure ≥160/105 mm Hg sustained over ≥15 minutes) and further classified individuals with severe hypertension as having received timely (within 60 minutes) or delayed treatment. Severe maternal morbidity was identified using a composite measure developed by the Centers for Disease Control and Prevention. We calculated overall and indicator-specific rates of severe maternal morbidity for 4 categories of deliveries: without hypertensive disorder of pregnancy, with hypertensive disorder of pregnancy without severe hypertension, with severe hypertension and timely treatment, and with severe hypertension and delayed treatment. We assessed the association between hypertensive disorder of pregnancy, severe hypertension, timeliness of treatment, and severe maternal morbidity using multivariable robust Poisson regression, adjusting for demographic and clinical characteristics.

RESULTS

Of 3723 delivery hospitalizations within the study time frame, 32.3% (1204/3723) were complicated by presence of a hypertensive disorder without severe hypertension and 5.7% (211/3723) by presence of a hypertensive disorder with severe hypertension. Among those with severe hypertension, 48.8% (103/211) received timely treatment. Compared with deliveries not complicated by a hypertensive disorder, severe maternal morbidity risk was increased for hypertensive disorder of pregnancy without severe hypertension (124.4/1000 vs 52.0/1000; adjusted risk ratio, 1.84; 95% confidence interval, 1.41-2.40), severe hypertension with timely treatment (233.0/1000; adjusted risk ratio, 3.81; 95% confidence interval, 2.45-5.92), and severe hypertension with delayed treatment (305.6/1000; adjusted risk ratio, 5.38; 95% confidence interval, 3.75-7.73).

CONCLUSION

Patients with hypertensive disorders of pregnancy are at an elevated risk of severe maternal morbidity, and development of severe hypertension further increases this risk. Timely antihypertensive treatment is associated with lower risk of severe maternal morbidity among those with severe hypertension. These findings emphasize the importance of provider education and quality improvement efforts aimed at expediting treatment of severe hypertension.

Impact of Implementation of the Maternal Fetal Triage Index on Patients Presenting with Severe Hypertension

BACKGROUND

Severe hypertension remains one of the leading preventable causes of maternal mortality in the United States. Timeliness to response to severe hypertension in pregnancy is a critical quality indicator tracked by state and national organizations. We hypothesized that implementation of the Maternal Fetal Triage Index, a validated acuity tool, would improve care performance in women with severe hypertension in an urban, inner-city hospital setting.

OBJECTIVE

Our objective was to assess the impact of the Maternal Fetal Triage Index on the management of women presenting with severe pre-eclampsia diagnosed by severe hypertension as measured by time to provider assessment, administration of magnesium sulfate, and immediate administration of acute antihypertensives.

STUDY DESIGN

This was a prospective, observational study of pregnant women presenting to labor and delivery triage unit with severe pre-eclampsia diagnosed by severe hypertension delivering at a large urban inner-city academic facility before (Epoch 1: January 1, 2019- December 31, 2019) and after (Epoch 2: March 1, 2021- September 31, 2021) implementation of the Maternal Fetal Triage Index. Baseline outcomes of time to assessment, time to magnesium sulfate prophylaxis, and time to antihypertensive medication administration prior to implementation of the Maternal Fetal Triage Index were assessed. The Maternal Fetal Triage Index tool was implemented on March 1, 2021, following standardized education in 2020 for all triage nurses, unit technicians, healthcare unit coordinators, and healthcare providers. Time to assessment, administration of magnesium sulfate prophylaxis, and time to antihypertensive administration following implementation of the Maternal Fetal Triage Index were compared with pre- Maternal Fetal Triage Index measures. Statistical analysis included Wilcoxon rank sum test with P< 0.05 considered significant when comparing epoch 1 to epoch 2.

RESULTS

A total of 370 patients were admitted with severe hypertension in 2019 prior to the use of the Maternal Fetal Triage Index, and 254 patients were admitted with severe hypertension in 2021 after the Maternal Fetal Triage Index was implemented. There were no differences between epochs across baseline characteristics including age, race/ethnicity, parity, and body mass index. After the Maternal Fetal Triage Index was implemented, time to provider assessment was significantly improved, from median time of 44 [0, 65] minutes in epoch 1 to 17 [0, 39] minutes, P<0.001 in epoch 2. Time from arrival to magnesium sulfate prophylaxis was also significantly faster with median time of 161 [109, 256] minutes in epoch 1 vs. 127 [85, 258] minutes, P=0.001 in epoch 2. There was also a decrease in time from arrival to antihypertensive medication administration for severe blood pressures after implementation of the Maternal Fetal Triage Index (101[61, 177] minutes vs 66 [35, 203] minutes, P<0.001).

CONCLUSIONS

Implementation of the Maternal Fetal Triage Index at a large urban inner-city hospital was associated with improved timeliness of assessment and treatment of women with severe hypertension. The Maternal Fetal Triage Index is a viable mechanism to improve efficiency among triage units- specifically in the management of severe hypertension.

Elevated Blood Pressure in Women of Childbearing Age in the United States

PURPOSE

Elevated blood pressure is frequently associated with adverse health issues among women during and after childbirth in the United States. The purpose of this study was to describe incidence of and determine predictors of prehypertension and hypertension among women of childbearing age in the United States.

STUDY DESIGN AND METHODS

Using secondary data analysis, existing data from the National Health and Nutrition Examination Survey (NHANES; 2013-2018) were used to address study aims. Inclusion criteria were women in the age range commonly considered to be of childbearing age, 15 to 44 years of age. Simple random sampling was to select subjects from the 2,932 women in the NHANES dataset who met inclusion criteria. We calculated a sample size as adequate for the statistical group comparison to be significant with a power of 95% to detect a difference among groups. An ordinal logistic regression model was created to discriminate predictors of normotensive blood pressure, prehypertension, and hypertension.

RESULTS

The sample (n = 393) included 300 women with normal blood pressure, 46 women with prehypertension, and 47 with hypertension. Older women (within childbearing age range), women with high body mass index, and African American women are highly likely to have prehypertension and hypertension.

CLINICAL IMPLICATIONS

Contrary to previous research, poverty income ratio was not associated with prehypertension and hypertension. Future research should test interventions that include promoting heathy lifestyles and address elevated body mass index. Interventions should be tailored to be culturally appropriate for African American women and older women within this age range.