Semiautonomous Treatment Algorithm for the Management of Severe Hypertension in Pregnancy

Abstract

OBJECTIVE: To evaluate whether implementation of a semiautonomous treatment algorithm was associated with improved compliance with American College of Obstetricians and Gynecologists guidelines for rapid administration of antihypertensive therapy in the setting of sustained severe hypertension. METHODS: This was a single-center retrospective cohort study of admitted pregnant and postpartum patients treated for severe hypertension between January 2017 and March 2020. The semiautonomous treatment algorithm, which included vital sign monitoring, blood pressure thresholds for diagnosis of severe hypertension, and automated order sets for recommended first-line antihypertensive therapy were implemented between May 2018 and March 2019. The primary outcomes were the administration of antihypertensive therapy within 15, 30 and 60 minutes of diagnosis of severe hypertension. Comparisons were made between the preimplementation, during implementation, and postimplementation groups using χ2. Analysis was limited to the first episode of severe hypertension treated. Statistical significance was defined as P<.05. RESULTS: In total, there were 959 obstetric patients treated for severe hypertension, with 373 (38.9%) treated preimplementation, 334 (34.8%) during implementation, and 252 (26.2%) after implementation. Treatment of severe hypertension within 15 minutes was 36.5% preimplementation, 45.8% during implementation, and 55.6% postimplementation (P=.001). Treatment within 30 minutes was 65.9% in the preimplementation group, 77.8% during implementation, and 79.0% in the postimplementation group (P=.004). There was no difference in percentage of patients treated within 60 minutes (86.3% before, 87.7% during and 92.9% after implementation, P=.12). CONCLUSION: Implementation of a semiautonomous treatment algorithm for severe hypertension was associated with a higher percentage of pregnant and postpartum patients receiving the first dose of antihypertensive therapy within 15 and 30 minutes. Implementation of similar algorithms for this and other obstetric indications may decrease time to appropriate therapy and help improve care equity.

Implementation research priorities for addressing the maternal health crisis in the United States: Results from a modified Delphi study

“…47,48 Implementation of nursedriven and semiautonomous treatment algorithms for peripartum hypertension have shown promise at providing appropriately timed treatment. 49,50 Yet, these clinical examples represent just the tip of the iceberg of implementation; larger-scale implementation studies are needed to determine how best to incorporate these practices into the diverse maternity populations and practice models that exist in the United States.…”

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

“…18,19 Implementing electronic clinical pathways well can directly impact the clinical care provided by improving medication administration, encouraging appropriate evaluation for diagnosis or treatment, avoiding low-value care, decreasing the LOS, decreasing the need to transfer to a higher level of care, and improving overall health outcomes. 20,21 The ACP led to obvious decreases in the variation between providers in the various patient care settings. Standardization of care through pathways decreases PICU LOS, overall hospital LOS, duration of receiving albuterol, and time to transition from continuous to an intermittent inhaled bronchodilator.…”

“… 18 , 19 Implementing electronic clinical pathways well can directly impact the clinical care provided by improving medication administration, encouraging appropriate evaluation for diagnosis or treatment, avoiding low-value care, decreasing the LOS, decreasing the need to transfer to a higher level of care, and improving overall health outcomes. 20 , 21 …”

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

“…Data increasingly link maternal vascular, metabolic, and inflammatory complications of pregnancy and postpartum with an increased risk of vascular disease in later life (Whelton et al, 2018). Successful efforts by health care providers and organizations have addressed hypertension and other severe complications during hospitalization for childbirth (Martin, Hamilton, et al, 2021; Martin, Pappas, et al, 2021; O'Brien et al, 2018), but few have concentrated on attending to remaining health risks to women after hospital discharge (United States Government Accountability Office, 2020). Given sufficient resources and focused guidance, the birth experience could act as a sentinel event for women to take measures to manage chronic diseases, change behavioral risk factors and promote their own health, in line with recommendations by the American College of Obstetricians and Gynecologists (2018).…”