Implementing an adapted patient safety bundle for pregnancy-related severe hypertension to improve recognition,...

Severe hypertension (HTN) during pregnancy is highly associated with adverse perinatal outcomes, yet many cases occur in outpatient settings where standardized management is lacking. We used a community-engaged approach to adapt an evidence-based inpatient HTN bundle for outpatient care, creating the Outpatient HTN (O-HTN) Bundle. This study aimed to evaluate the feasibility, acceptability, and impact of three implementation strategies (1) identifying and preparing champions, (2) providing ongoing training, and (3) simulation.

We conducted a pre-post pilot study in three Federally Qualified Health Centers (FQHCs) from 9/2021-6/2022. Multidisciplinary clinical teams comprised of a medical assistant, nurse, provider (midwife or physician), and pharmacy staff received training on the O-HTN Bundle and participated in pre- and post-training simulations. Simulations involved a patient actor presenting with severe HTN during a prenatal visit. Trained observers used a checklist to evaluate clinical team fidelity to the O-HTN Bundle algorithm. Observers, clinical team members, and the patient actor assessed provision of respectful care via a Respectful Care Reflection Tool. The primary outcome was fidelity to the O-HTN Bundle; secondary outcomes included respectful care and feasibility and acceptability of the implementation strategies. Feasibility was defined by engagement in trainings/simulations. Acceptability was assessed with a study-specific survey. Paired t-tests compared fidelity and respectful care scores pre- and post-training. Descriptive statistics summarized acceptability and feasibility data.

The implementation strategies were feasible; 19 clinical teams participated, representing 59% of all prenatal providers across the three FQHCs. All 19 teams participated in the O-HTN Bundle training and pre- and post-training simulations. The strategies were also effective: mean fidelity scores improved from 78% pre-training to 95% post-training (p = 0.006). Significant gains were made on severe HTN identification, treatment, and escalation to higher level of care. Respectful care scores also improved, though not significantly. Survey results indicated acceptability of the training and simulation model.

In this pilot study, clinic champions, training, and simulation were feasible, acceptable, and effective strategies to improve fidelity to the O-HTN Bundle and thus response to severe HTN in pregnancy. These findings support broader implementation of the O-HTN Bundle.