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Improving Obstetric Hypertensive Emergency Treatment in a Tertiary Care Women's Emergency Department
Rosemary J Froehlich1, Lindsay Maggio, Phinnara Has
1Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; the Department of Obstetrics and Gynecology, Women & Infants Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; the Department of Obstetrics and Gynecology, High Risk Pregnancy Consultants, Florida Hospital Medical Group, Maitland, Florida; and the Department of Obstetrics & Gynecology, Duke University, Durham, North Carolina.
Objective:
To assess treatment outcomes associated with an obstetric hypertensive emergency quality improvement intervention instituted in a tertiary care women's emergency department.
Methods:
We conducted a cohort study of pregnant (20 weeks of gestation or greater) and postpartum (6 weeks of gestation or less) women treated for hypertensive emergency (systolic blood pressure [BP] 160 mm Hg or greater, diastolic 110 mm Hg or greater, or both) before and after a quality improvement intervention. A multidisciplinary task force revised clinical guidelines and nursing policy, updated electronic order sets, and provided staff education and clinical management aids. Data were collected by electronic chart review. The primary outcome was achieving goal BP (systolic 150 mm Hg or less and diastolic 100 mm Hg or less) within an hour of initial therapy. Secondary outcomes included time from first severe BP to 1) first antihypertensive treatment and 2) goal BP.
Results:
There were no significant differences in baseline characteristics in the preintervention (n=173; September 2014 to September 2015) and postintervention (n=173; December 2015 to November 2016) groups, including gestational age, days postpartum, maternal age, race-ethnicity, or comorbidities. We found no significant difference in primary outcome frequency: 41% achieved goal BP within 60 minutes preintervention vs 47% postintervention (P=.28). Median time from first severe BP to first treatment was unchanged (30 minutes preintervention vs 29 minutes postintervention, P=.058); however, median time from first severe BP to goal BP decreased significantly (122 vs 95 minutes, P=.04). Confirmation of hypertensive emergency within 15 minutes (recommended) was only achieved in approximately 20% of women in either group. More women initially received intravenous antihypertensive treatment after the intervention (52% preintervention vs 80% postintervention, P<.001).
Conclusion:
A quality improvement initiative was not associated with more women achieving BP control within an hour of obstetric hypertensive emergency treatment, but was associated with decreased time to achieve control. This suggests improved clinical practice after the intervention.