Hypertensive Disorders of Pregnancy
29
August

By Adem Lewis / in , , , , , , , , /


>>Welcome, and thank
you for standing by. At this time all participants
are in a listen only mode until the question and answer
session of today’s call. Today’s conference
is being recorded. If you have any objections,
please disconnect at this time. I would now like to
turn the conference over to Dr. Zsakeba Henderson. Dr. Henderson, you may begin.>>Good afternoon. My name is Zsakeba Henderson, and I lead the state-based
Perinatal Quality Collaborative activities in the Division of
Reproductive Health here at CDC. And I would like to welcome
you to the third presentation in our second series of
webinars we are sponsoring on perinatal quality
collaboratives. Today’s presentation is about hypertensive
disorders of pregnancy. And we’ll include a discussion
of quality improvement projects and recent guidelines proposed
for response to and management of hypertensive disorders
of pregnancy. Our presenters today
are Dr. Marilyn Kacica and Nancy Peterson. At the end of all
the presentations, you will have the
opportunity to ask questions and participate in
the discussion. A recording of this webinar will
be archived and made available on our webpage at http://www.cdc.gov/
reproductivehealth/ MaternalInfanthealth/ PQC.htm. Downloadable handouts will
also be made available, and may be accessed by
clicking the handout tab at the upper right
side of your screen, and then selecting the files
to download to your computer. For additional information
from CDC about severe maternal
morbidity in the United States, you can also go to http://www.cdc.gov/
reproductivehealth/ MaternalInfantHealth/
SevereMaternalMorbidity.html. Our first speaker is
Dr. Marilyn Kacica. Dr. Kacica is the medical
director of the Division of Family Health within the New
York State Department of Health. She provides leadership
for New York State Maternal and Child Health Epidemiology
and Program, Health Informatics and Quality Improvement. She is a board certified
pediatrician, with subspecialties
in infectious diseases and preventive medicine. Dr. Kacica is a fellow of the
American Academy of Pediatrics, and clinical professor
of epidemiology at the State University
of New York, University of Albany
School of Public Health. Dr. Kacica has served
in leadership roles in quality improvement
initiatives dealing with asthma, school-based health centers,
and currently as the director of the New York State
Perinatal Quality Collaborative. I will now turn the presentation
over to Marilyn Kacica.>>Thank you, Keba. So I’m going to talk about
guidelines that we developed over the past year on
hypertensive disorders in pregnancies for
healthcare providers. So New York State has a
comprehensive maternal mortality review process that was
implemented in 2012. In this — we have a committee,
an expert review committee that advises us on what we find. This committee is
multidisciplinary in nature, and we have a lot of participation
from the committee. It really represents over 20
professional organizations and hospitals across the state. I wanted to give you an example
of some of the associations that work with us
on this process. And we try to include everyone
who might be a pregnant woman, or a woman who was
intending to get pregnant. So we, of course,
work with ACOG, we have our New York
State Nurses Association, we included midwives, family
physicians, anesthesiologists; we have the Dietetic
Association since obesity is such a large issue in what
we see, emergency physicians, et cetera, as you can look at. So this committee reviews the
aggregate data that we present to them from our review process,
and then discusses the trends, what are the emerging
issues that we’re seeing, and then makes recommendations
for prevention measures, and how we might be able to
improve care and the education to decrease our maternal
mortality rate. [ Silence ] Through the review of our data,
we saw that the top 4 causes of maternal mortalities were
hypertension, hemorrhage, embolism, and infection. And the department had
already previously worked — had worked on hemorrhage
earlier, and had developed a poster that
is being used by facilities. So it was decided that hypertension should be
the focus of our next efforts. [ Silence ] When we looked at
hypertension in general, we saw that hypertensive
disorders are 5 times more prevalent in maternal deaths, as
you might see in the population. And we looked at this through
reviewing our birth records, versus what we were finding in
our maternal mortality reviews. We had a rate of — we saw
26% of our deaths had — were associated with
hypertension; whereas 5% of women
who had given birth and had a live birth recorded. [ Silence ] We also have begun looking
at severe maternal morbidity within the state, and we found that hypertensive disorders
contribute to almost a quarter of severe maternal morbidity. When we looked at our
data for 2008 to 2011, we saw that we have a rate
of 274 per 10,000 deliveries of severe maternal
morbidity, and of these, 63 per 10,000 deliveries was
associated with hypertension. [ Silence ] So once the expert review
committee, you know, looked at the data with us, we
decided that a guidance document for healthcare providers who
care for women in a variety of clinical settings,
not only obstetricians but say an emergency
physician who might see a woman who comes in, or a nurse
midwife, or a nurse. We wanted to make sure that
they were able to recognize and understand what
should be done. So when hypertension was
identified as a priority, we looked to this
group for volunteers to help us develop these
guidelines for the evaluation and management of HDP. [ Silence ] So as I said, it was for a
variety of clinical settings, and we wanted to
promote quality services that enhanced communication
among providers, because what we were
finding is that a lack of communication was
really part of the problem. The committee went through this
process by providing a summary of existing guidelines and
documents, and then some — and subcommittee consensus. So they did a thorough review
of what was already out there. And we went — we began this
process and we knew this was not to replace clinical judgment
and caring for women, because, you know, certainly a guidance
document can’t do that, but we just wanted to make sure that everyone had the
appropriate tools available, and the most current knowledge. [ Silence ] The review and comparison of the guidelines included
practice bulletins, committee opinions, and then
some additional literature recommended by subcommittee
members. So something new had come
out during the process that was also put in the review. The guidelines that were
considered, we used guidelines that were already out there
for the United Kingdom, from Canada, from Australia. And the New York
State Department of Health had already published
a paper on hypertension in diverse populations
that focused on the Medicaid populations. We also reviewed ACOG
documents that were out there that addressed perinatal care,
the management of preeclampsia and eclampsia and
chronic hypertension. [ Silence ] So the subcommittee
discussed the findings of the draft documents,
and an executive summary and narrative document
was put together and distributed to
the subcommittee. There are a lot of iterations
of this within the committee, and then back to the larger
maternal mortality review committee for signoff. And also there was a
review process internally at the Department of Health. Some of the content of
the guidance document, we initially started
out with definitions. We wanted to make sure that everyone understood how
we were defining things so that when we were talking
about a certain subject, everyone understood it was
on the same playing field. We began with assessment,
and we talked about how to actually perform blood
pressure measurement, you know, what is the technique, what kind of conditions do you conduct
it under; and we also talked about proteinuria screening. There was, you know, a lot of
information on the risk factors for preeclampsia, how
do you assess, you know, what is the baseline
renal functions, what type of laboratory
testing; how do you reduce risk for hypertensive disorders
for high-risk women. We talked about low-dose
aspirin use, the ambulatory care of chronic hypertension, so women who already
have hypertension, how are they managed? We also wanted to talk
about diet and lifestyle in association with the whole
concept of well woman care. [ Silence ] When we talked about treatment,
we wanted to make sure that everyone understood, you
know, the target and thresholds for non-severe hypertension
and severe hypertension. There was a discussion of
treatment using labetalol, nifedipine, and methyldopa,
and also surveillance for hypertension, both
maternal and then fetal as far as frequency of testing
and monitoring. Some of the inpatient prenatal
care issues that we talked about were indications
for inpatient, what kind of hospital
protocols were there, and what were appropriate; what kind of discharge
instructions should be given to a woman; make sure that there’s communication among
healthcare providers, patient and family; some
sample order sets; these are seizure
prophylaxis and management, and we also talked
about HELLP syndromes. Other topics included antinatal
steroids, fluid balance, and thromboprophylaxis. [ Silence ] As far as delivery
and intra-partum care, discussions included delivery
timing, the mode of delivery, anesthesia, and then postpartum
care and risk communications. So the document was meant to be
as comprehensive as possible. We wanted to focus on
outpatients and inpatients to make sure that
we were reaching as many providers as we could. So this — the guidance
document was rolled out at our annual Maternal
Mortality Review Meeting. And we have posted
this guideline on the New York State
Department of Health website. We’ve also widely
disseminated it to hospitals across the state, to health
plans across the state; and our partner organizations
have also linked to it from their websites. [ Silence ] As a part of our rollout
plan, we always wanted to go the next step then and
to see what kind of point of use tools would be useful in
association with the guidelines? We all know that
sometimes guidelines are put out on shelves and never seen
again, and we didn’t want that to be the case with these. So as we were going forth
with these discussions, we were fortunate enough to
apply and receive an award from AMCHP, as part of the
Every Mother Initiative. And this award was being used — they wanted to focus on
translation of activities from an issue that
was identified through maternal
mortality reviews. So I think that this took very
well with sort of the process that we were going for. So since we had identified
hypertension, we had developed the guidelines, and the next step was
translation for us. That is what we focused
on in this grant. So some of the things that
we are working on currently in our hearing in Amden
[phonetic] are we’re putting together provider training
for continuing education, so a PowerPoint presentation
that will be narrated that will be online, that
will be presented initially and then archived so that
providers can take it when it is convenient for them. Other tools that we are working
on are an outpatient tool, sort of demonstrating
the highlights around measuring blood pressure. And we think that this
tool will be useful in the outpatient setting,
in the clinic setting, private practices, as well
as within the hospital. We’re working on an
emergency department tool. There’s an algorithm that
was developed by CMQCC that you’ll probably hear
about that we are adapting for New York State, as well as a preeclampsia
early recognition tool. And we’re also working with the
Preeclampsia Foundation as far as the patient education tool
that will focus both on pregnant and postpartum women so that
they understand the sort of symptoms and signs
of hypertension, and know to contact one of
their healthcare providers. So as you can see from
this slide, you know, California has already begun
— has developed these tools, and what we are doing
is working with them to adapt them for
New York State. So I think this is a great
sharing opportunity, and, you know, we certainly
appreciate the efforts that went into these tools. The other piece that
we are doing since we have the guidelines,
we’ll be developing these tools, is that through our perinatal
quality collaboratives obstetrical improvement
project, we are going to incorporate what we’ve
learned about this morbidity and mortality into that project. So we’re working
in collaboration with the New York State
Partnerships for Patients, which is the EMS funded
initiative within our state that we work with, to
incorporate hypertension and hemorrhage into our project. We’re doing this through
curriculum development so that we’re going to put it
in the collaborative model. We’ve already begun
coaching calls with them, and we’re having a learning
session the beginning of April. We will have educational
webinars on the topic. And we have developed a process
in outcome measures related to both topics, but
for this, you know, we have one around hypertension that they will begin
collecting data. So I think that this is sort
of a continuum of this process that we began by
identifying an issue. We developed guidelines, we
have point of care tools, and now we’re going to
be working specifically with our facilities to
put these tools to use and hopefully improve
outcomes in hypertension. I want to acknowledge
the help I had with the whole project
certainly, and with this presentation,
specifically Dr. Lazariu and Kristen Lawless,
who are both integral to this presentation. So I want to thank
them for their efforts. So thank you for your time,
and I’ll turn it back to Keba.>>Thank you so much, Marilyn, that was an excellent
presentation. Our next speaker
is Nancy Peterson. Nancy Peterson is a
perinatal nurse practitioner who for the past 30 years has
performed a variety of roles as a labor and delivery
nurse, nursing faculty, clinical nurse specialist,
childbirth educator, and sexual assault
nurse examiner. She completed her BS in
nursing at Point Loma College in San Diego, and her MSN at
Regis University in Denver. Currently she is a director
of perinatal outreach at Stanford University, and
the clinical program manager of the California Maternal
Quality Care Collaborative. For the past 2 years, she has
co-chaired the preeclampsia taskforce to develop a toolkit
to improve the early recognition and treatment of preeclampsia, which was released
in January 2014. Most recently she
has been the co-chair of the California Statewide
Preeclampsia Collaborative, involving 25 hospitals
to implement the toolkit, and collect data with the goal
to reduce maternal morbidity and mortality associated
with preeclampsia. I’ll now turn the presentation
over to Nancy Peterson.>>Thank you so much, Keba. Can everyone hear me all right?>>Yes.>>Oh, okay. Thank you so much
for the opportunity to share our work
with all of you. It has been an amazing process,
and, you know, it’s really been over the last year
doing the collaborative with our hospitals, you know,
we have been able to realize such a great improvement
in processes and outcomes in our
25 hospitals. So I’m going to share — what
I thought I’d do is briefly go over kind of our process with the pregnancy associated
maternal mortality review, and how we’ve used that data
to drive the development of the toolkit, and then
give you some highlights from the toolkit. So much of what we
did is similar to what Marilyn just described. We really used ACOG guidelines to guide our toolkit management
strategy, but also just to share some highlights of some
of the tools that we developed, and then end with a little
bit about the collaborative and show you some preliminary
results that we have so far. So I just want to acknowledge
— oops, I know where my — there we are — that
this was a process that involved numerous
people throughout the state of California, just
experts in their field, very much multidisciplinary. And we partnered with the
Preeclampsia Foundation so that we really made sure we
got the patient perspectives, and included that in the
development of the toolkit. We had just a wonderful
group of people that really stepped
up to the plate. And I’m just so proud to have
been honored to work with them. So initially — this is
probably not new news to you, and I’m sure many of you
have already seen this slide, but this is our California
maternal mortality rate over 30 years, from
1970 to 2010. And as you see from 1970
the trend was downward, until about 1985 or ’84 when
it started to move upward. And the state of California
became very concerned about that, and in
2006 basically decided to form the California
Pregnancy-Associated Maternal Mortality Review Committee
that started reviewing cases from 2002 to 2004 was
the initial cycle. And so this process
really has been where we — the cases were identified
through the state and [inaudible] data,
and ICD 9 codes. They collected all the
information, got the charts of all the maternal deaths
that were pregnancy associated, and we formed this
committee of, again, experts from throughout
the state that was multidisciplinary,
so we had anesthesia, cardiologists, MFM’s,
nurse midwives, clinical nurse specialists,
staff nurse. I mean, we basically had
everybody that could be related to it, anesthesia, and we reviewed each
case very thoroughly and determined the cause of
death, and then asked based on all of the review information
that we obtained, what were some of the contributing
factors to that death, and out of those contributing
factors, were there — what quality improvement
opportunities were there? And we actually asked the
committee to rate whether or not there was — there
could have been a chance to have altered the outcome if the management
had been different. And I’ll show you
some data from that. So from all of this data,
then, we developed — decided which toolkits
we would do. And hemorrhage was first, and many of you have
already implemented or started the implementing
of the hemorrhage toolkit, and preeclampsia now
is just getting going. And our next one
is in development, and that will be a
cardiovascular toolkit. So when you look at — this
is the California PAMR, which is Pregnancy Associated
Maternal Review Committee, causes of death —
well this is the top 5, you’ll see that cardiovascular
disease is actually our top cause of death. However, preeclampsia was
second with 25 deaths, or 17% of all deaths
were from preeclampsia. [ Silence ] And when you looked at that
thing about grouped cause of death and was there a
chance to alter outcomes, you can see that
preeclampsia, eclampsia deaths from that were — all of the
deaths had at least some chance to evolved with the
outcome, every single. And even though the numbers
are small, 25 deaths out 145, still every single one
had some opportunity to have changed the —
or altered the outcome. So we really found this was
something we really needed to focus on. And as you know, I mean, even
though the number of mortalities with preeclampsia is very small, it’s really the tip
of the iceberg. And underneath that is
all of the near misses, which we estimate
about 400 a year, and serious morbidities
is about 3400 a year. And so this is where we chose
to really focus the toolkit on, and to get the biggest impact
in outcomes is focusing on the near misses
and serious morbidity. So the other thing we
looked at is not just women that had a diagnosis
of preeclampsia, but women that had
diagnosis of hypertension; because in California that trend
is really escalating as well, up to 6.3, which is in line
with the national average of 5 to 10 percent of all pregnant
women have hypertension. So in our cohort from
2002 to 2004, which again, was 145 pregnancy-related
deaths, was 17% were grouped as preeclampsia/eclampsia. But when we looked overall, 39% of all of those
deaths had a diagnosis of hypertension somewhere
in their medical record, whether it was in the
inpatient prenatal period, or preexisting chronic
hypertension. So that is a huge area
that we need to focus on. And when you look at
hypertension morbidity, this was a graph that we put all
the categories of hypertension. It was our — using our linked
dataset, and comparing — if you look at the 2
categories of eclampsia and severe preeclampsia,
compared to those women who had no hypertension, the actual severe morbidity
rate was 26 fold in women that had eclampsia and severe
preeclampsia over those women who had no hypertension. And even women who had just any
hypertension diagnosed had a 7.3 fold increase in
serious morbidity, compared to those women who
had no history of hypertension. So, again, the morbidity
is really significant. And we can really make
an impact on that. And then when you ask, you
know, what do women actually die of when you talk
about preeclampsia, well it’s generally we
found that in our cohort, as well as I’ll show
you the next slide, with what the CDC found as
well, that 87% of our women — or 64% died of stroke,
and out of those 87% were from hemorrhagic stroke,
and that goes along with the national
findings as well. And this was the CDC review
of 14 years of coded data, over 4,000 maternal deaths, and
about 19, almost 20 percent were from preeclampsia, and as well
they found that 90% of all of those deaths were also
from hemorrhagic stroke. So we also looked at
what factors contributed to the deaths. And we had a whole list of
factors that we kind of graded. And if you can see, that under
the healthcare professionals 96%, basically 24 out of those
25 deaths had some healthcare provider related issue. And most of those, 92%, were
related to delaying diagnosis; that for some — they were just
not managing these patients quickly, and identifying
and recognizing the disease. And so because of that
also there was a lot of ineffective treatment. 79% of the patients did
not get the treatment that they needed
in a timely manner. There was also some
patient factors, 64% of the cases had
some issues related to — you know, many of these
patients had a delay in actually seeking care. Many of them came in
post-delivery to the ED after being at home for several
days with severe headaches, and didn’t know that they
were supposed to, you know, notify a healthcare provider. There was a lot of, you know,
just not enough education, they were not given
any written information about what symptoms they needed to notify someone
right away with. So there was a lot of that
patient education information that came out of
these cases as well. So out of that poll review
of the data, we really came up with some quality
improvement themes related to preeclampsia that
we focused on. And that was really, again,
the early recognition response to clinical triggers; because
on many of these cases, in fact almost all of them,
we saw that despite triggers that clearly indicated that
the mother was seriously deteriorating in her condition, the healthcare providers really
either didn’t recognize it, or didn’t respond
in a timely manner, and it led to numerous
delays, not only in diagnosis, but obviously treatment. We also found that
there was a huge issue with accurate blood
pressure measurement. And this came about with
actually in many of my — as I’m going out through the
country talking to people about blood pressure control,
and asking nurses really, you know, “How do you
take a blood pressure?” What we’ve been finding
is that many nurses, even though initially
they take a blood pressure with a patient sitting upright,
they often will lay them in a lateral position
and retake it, and lo and behold the blood
pressure is now normal or lower. And so we found a number
of cases that patients came in for an induction
for preeclampsia, and after repositioning
them in a lateral position, their blood pressure
lowering, were sent home — canceled the induction and
were sent home to come back with severe morbidities,
or a stroke. So we recognize that we really
need to educate providers and nurses about the
accurate blood pressure, and when we’re really talking about comparing apples
to apples. When, you know, you’re
looking at prenatal records, and you’re looking at trends,
and you’re comparing it to what you see now, most people in the prenatal setting are
being — sitting upright, getting their blood pressures
taken, and we need to kind of continue that same
continuity of accuracy in the hospital setting; and then initiating hypertensive
meds early and aggressively. We also recognize
that there was a — we needed to really focus on
improving coordination of care through not only
multidisciplinary management, but also between units of the
hospital, like ED, and Labor and Delivery, and Postpartum,
and certainly the ICU if any of our patients end up there;
and also between hospitals, because, again, there were
numerous transport issues with patients arriving in a
rural hospital with, you know, no resources to really
take care of them, and certainly no
consultative specialists there to manage these patients, and
didn’t recognize, you know, how important it was
to transport them to a higher level of care. So we really need to
work on that aspect. And then improved postpartum
follow-up care, which I’ll talk about in a few minutes; and
then again, huge about we need to do a better job with
educating our patients and using appropriate
literacy levels to do that. So I want to share with
you a few highlights and clinical pearls
from the toolkit. And, you know, basically some of you may have already
downloaded it. If you haven’t already,
I encourage you to. I’ll give you information on
how to go about doing that. But basically we
started with trying to keep it pretty focused. But as you can see, we really
kind of got carried away, because we recognize that
everything was so important. But we really —
it focused it on — you know, the introduction
is really kind of the background
information, and then we talked about patient care and
treatment recommendations, so it’s really —
covers a huge spectrum of pretty much everything
related to preeclampsia. And then we included a
chapter on emergency department and non-obstetrical visits,
again, to really focus on the need to work with our
ED colleagues to make sure that we communicate effectively, and that we’re basically
no matter which area that patient arrives,
or is located, that we’re all using a
standardized approach to management of these patients;
and then a whole chapter on education and
patient information. So this is — actually came
right out of the toolkit, and again, it really stresses
the point about importance of making sure that everyone
is taking an accurate blood pressure measurement,
and it’s consistent. So all of our collaboratives — and I’ll talk about
the hospitals, started at the very
beginning with education to those nursing staff
about being accurate and being consistent; and
not repositioning laterally to obtain a lower
blood pressure. So we talked a lot about that. And then we recognize obviously
that you need to have some kind of an organized tool to help
people identify the clinical signs or triggers that help
you with the early recognition and to avoid that delay in
diagnosis and treatment. So we utilize the early —
the United Kingdom MEOWS tool, which was the Modified
Early OB Warning System tool that they developed. And we kind of used
that as our guideline and adapted it to this. And we really wanted to look
at something that, again, would help us kind of as a
disease progresses from kind of that mild to evolves to more
severe, to get people to start to recognize and intervene
in a timely manner. As part of this tool, the
next slide is a continuum of the tool, so that
basically if you — if all of your triggers are in
a green mode, then it’s normal, and you proceed with
your normal protocol. However, if you have any
triggers in the yellow column — and I know you didn’t
see that fast enough, but it is in our toolkit
that you can look at, if you had 1 trigger you
need to notify your provider. If there’s more than
2, you know, we give you some guidelines as
far as what you need to do next. And, again, you need to make
sure that the physician is aware that she’s moving on that
continuum to more severe. And then red — and,
again, any 1 trigger in any of these you’ll get an immediate
evaluation, consider transfer to a higher level of care, and it requires a
one-to-one staff ratio. And then if there’s trigger
under each of these areas of awareness, blood pressure,
chest, or respiratory status, then we give you some guidelines
of what you need to do next too. So this is, again,
there’s no validated tool. This is kind of a pilot. Some of our sites are piloting
this now, and I’m hoping to get more — better
outcome and see if we can get this validated;
but it’s a start anyway. The other thing that became
very clear as we were looking at our data was the timing
of pregnancy-related deaths. And, again, this was in
the 2002 to 2004 cohort. And as you can see in
this bottom table here of preeclampsia deaths,
68% of them were — actually died within 4 days
of delivery, and 98% or the — 96% occurred within
42 days of delivery, and only 1 death actually
occurred as an outlier way out to 6 weeks or longer. But all 3 — all but 3 of
the deaths that occurred of these 25 had a diagnosis
of severe preeclampsia or health syndrome on
admission to the hospital. So it really pointed to the
fact that many of these women that were dying within 4 days
had already been discharged or were coming back
through the ED, and were — ended up in one of our
expert panel members, as well as on the
taskforce was an ED physician who really gave us a lot
of valuable information about the realities of
the ED, and that many of these women unless there was,
you know, something really — they were noticeably unstable,
sat in a waiting room for, you know, up to 8 hours, sometimes with severe
range blood pressures and were not being seen or
triggered an immediate — coming to the front of the line. So it really pointed to the
fact that we really need to work with our ED colleagues
to make sure that they identify
these women early. And also many of
them were coming in with their chief complaint
of a headache, and about 80% of them actually had a headache
as their chief complaint, and ended up sitting in the
waiting room and stroking. So early follow-ups for all of
our patients with preeclampsia so that anybody who is
diagnosed with preeclampsia in the hospital setting and was
sent home on medications needed to be seen within 3 to
7 days of discharge. And then if they were
not on medication but they were diagnosed
with preeclampsia, they needed to be seen
within 1 to 2 weeks so that they could be
followed up very closely, since many of these
patients, again, were the ones that came back through
the ED and died. And then any patient
that presents to the ED in the initial postpartum
period or up to 6 weeks really we
encourage them to initiate and get OB involvement
early on, because, again, many of them were not
even notifying the OB that that patient was there. So our treatment
recommendations, again, I’ll go through these very
quickly because they’re a lot of what Marilyn had
already talked about. But really the focus of our — the management of
preeclampsia was really to focus on recognizing it and
not to ignore some of those clinical signs or
the triggers that we saw time and time again in reviewing
the maternal deaths; to treat and control the blood
pressure in a timely manner and aggressively, giving mag
sulfate seizure prophylaxis, delivery at 34 weeks for severe
preeclampsia and 37 weeks for preeclampsia, those
diagnosed with preeclampsia, and then postpartum
surveillance and treatment. So these are the areas
that we really focused on. One of the key clinical pearls that I mentioned was really
a lot of these patients came in with very vague symptoms. And again, 80% were with
headache, but some of them came in with just abdominal
pain, shortness of breath, generalized swelling,
and, you know, “I just don’t really
feel very good.” And what we recognized is
that, you know, we really need to alert people that
even though many of these you can easily
say, “Well, you’re pregnant; those are kind of normal
common signs of pregnancy,” we really have stressed to
our collaborative members that at the very least if
these patients come and present to the hospital setting that — or even to the clinic
that a PIH panel or a lab panel should be
initiated before you discharge them home, just to really rule out that this is an atypical
form of preeclampsia; or at least to pay
attention to them. So our initial key
clinical pearl as far as initial first step
in decreasing morbidity and mortality is giving the
antihypertensive medications within 60 minutes of
documentation of a persistent, and that is more than 15
minutes is the ACOG definition of persistent, severe range
blood pressures of greater than or equal to 160 systolic,
and/or — and we use 105 to 110. We have decided to lower our
threshold just a little bit on the diastolic and give them
a little wiggle room to treat. And then ideally — and
that should be administered as soon as possible. So we started with
our collaborative — with a very lofty goal of
giving antihypertensive within 30 minutes, and we kind
of gave them a wiggle room of 30 to 60, but at the outset
60 is kind of the maximum. And what we found is we actually
have a preeclampsia toolbox that I’ll show you in a minute
that we implemented at Stanford and many of our collaborative
hospitals as well to facilitate really
getting these medications in very quickly; because
what we found is many IV antihypertensive meds
were not normally stocked in labor and delivery units. And they had to call
the pharmacy, and it took quite a
while to get it up. So we’ve developed
this preeclampsia box, which is similar to
the OB hemorrhage kit that many hospitals
have implemented to facilitate early
rapid treatment. You’re probably familiar
with the Martin Stroke data, and this is kind of what gave
us some insight into, you know, really if we’re — we’re really
trying to prevent stroke, which is the most severe — most
of our deaths were from stroke, and you look at his data,
100% of the women — and again, numbers
are very small, but 100% of the women have blood
pressures greater than or equal to 155, and 20% versus 12% had
diastolics between 105 and 110. So when we came up
with our guidelines, we actually are using ACOG of
systolic greater than or equal to 160 over 110, repeat the
blood pressure in 15 minutes, and if it’s still in that severe
range, then you treat them within 60 minutes that
we were saying ideally as soon as possible. And we’ve had — many in our collaborative
hospitals have been able to manage getting it
in within 30 minutes. So it is possible. But then we also
said that, you know, there are some alternative
triggers that it’s okay or you can consider giving it
with a systolic greater than or equal to 155 over
the 105 to 110. So we kind of gave
them that option. [ Silence ] Another key clinical
pearl is, again, using mag sulfate
therapy procedure for seizure prophylaxis in all
women with severe preeclampsia or with severe features. And it can be considered in
patients with mild preeclampsia. So we’re kind of leaving
it up to clinical judgment, but that it was still an option. And what we found — and just as
a side note, it was interesting when we were first starting
the collaborative and kind of getting — having
some of our calls, and seeing what barriers people
were up against, is that many of our sites were
reporting that many of the physicians just
started mag, and did not want to consider antihypertensives
because they, you know, made the assumption that starting mag would actually
lower the blood pressure. So we really had to focus
on some education with that, as well that mag sulfate is not
an antihypertensive medication, and move from there. This is an example of our
emergency medical box. And, again, the idea was to
have everything that you need if you have a person
that comes into the unit with severe ranged
blood pressures, and you have your loading dose
of mag, you have the IV tubing, IV bottles, everything that’s
already there ready to go, you’ve got your IV medication,
whether it’s IV labatelol or hydralazine, depending on what your hospital
facility uses. We also had PO nifedipine, so
if you can’t get IV access. So basically everything
is in this box contained, and we’ve used it
actually quite a few times and it’s made a huge
difference in our ability to get them managed
very quickly. We also know that using
preeclampsia specific checklists, doing a
lot of team training and communication is
really important to help — since, again, many hospitals
the numbers are very small of these women. So we have a whole section
in the toolkit on simulations and a lot of team building and
team communication scenarios with s-bar [phonetic],
all of those things that are very, very helpful. And then, again, really the
patient education strategies that are targeted to the
level of education that many of our patients are at. And again, partnering with the
Preeclampsia Foundation was such a wonderful experience
because they have this tool that they have so
graciously allowed us to put in the toolkit, and it is
available to order from them. But they did a lot of
surveys and studies looking at literacy level and using a
visual guide to give to some of these patients who
English is a second language. And this has been fabulous. So we — many of our sites
have gotten these onboard and handed them out
to all patients, as well as in the clinics. So in the time I have left, I wanted to just
share really quick — very quick, because I don’t
have much time left, in fact, I’m probably over my
time, a little bit about the preeclampsia
collaborative. And I’ll just go through
really, really quickly. Again, we had a
multidisciplinary expert panel to cover all bases. It started in January of
2013, and it’s going to August of 2014, and we actually
extended a little bit. We have 3 main aims, really
was to reduce the rate of severe morbidities in women
with severe preeclampsia, we did the percentage of women
with prolonged postpartum length of stays, and to achieve 100%
completion of the deliverables that we asked of them, and
that was we wanted them to do debriefs on all patients with severe range blood
pressures, and we wanted them to implement a policy and
procedure that was up-to-date. We had 2 outcome measures. One was severe morbidity
among women with preeclampsia/eclampsia,
and superimposed preeclampsia. And then looked at
postpartum length of stays, defined it as greater
than 4 days for vaginal, and more than 6 days for
Cesareans, two process measures, appropriate medical
management in a timely manner, and then debriefed, and then
we had a balance measure that I could talk about
if we had some time. So this is just some
preliminary data to show you that we really have made some
significant improvements. I mean, we still have
a lot of work to do, but we actually have made
some definite improvement. This orange line is
actually baseline, and the yellow line
is follow-up data. So our collaborative average
for severe morbidities — now this included
hemorrhage and transfusions, our average was 21.6, and after
follow-up and implementation, it was down to about 18%. But we recognized early on
that including hemorrhage and transfusions, so
that’s the vast majority of severe morbidities was going
to give us kind of a false sense of really what we were doing. So we have the ability
on our data center to exclude hemorrhage
and transfusions. And you can see when we do
that, that we still have — we see a lower percentage
of — it’s down to 6.6%, but we still have
made an impact. I mean, we’re down to 4.6%
as far as our follow-up data, so we’ve lowered the average after excluding hemorrhage
and transfusions. Postpartum length
of stays, again, our baseline average
was 7.2%, and we’re now at the third quarter of
2013, and we’re down to 6.3%; so a little bit better,
making some progress. And that was with both vaginal
and C-sections clumped together. This — in looking at medication
timing, we found out early on — we actually separated
it out into — the dark green is within 30
minutes, the lighter green is with — between 30 and 60
minutes, the yellow is 60 to 90, and then the orange is
greater than 90 minutes. So in this slide you
want to say green is go. I mean, that’s you really want
to increase the green area. And we did do that. You can see in November of 2012
our baseline data was 39.1%, and after the collaborative
in November it was 58.1%. So we’re making progress. Again, we still have
a lot of wiggle room, but what we identified was there
was some unmedicated group, that people were reporting that these patients even though
they had severe range blood pressures, were not
being treated. And so we came up — we
did a survey and came up with a list of reasons why. And one of the reasons
was actually that — there was an appropriate reason
why they weren’t being treated, and that was that their
blood pressure stabilized by the time they went and got
the medication and went back in the room to give it her
blood pressure was now not in the severe range,
and so they withheld it. So we now have — we’re
tracking that category, and we’ll know more hopefully
in the next 6 months. Our debriefs have
definitely improved to — it was half a percent at the
beginning of the collaborative, and now up to 18%, and some of our sites are
actually up to 100%. So these are some
process improvements that we’ve identified. Again, it’s critical
as you begin to start a preeclampsia
collaborative to make sure that everyone is on
the same page about how to take a blood pressure, what
the treatment thresholds are, and getting severe
preeclampsia order sets in line, as well as your policy and
procedure so that everybody, again, is using a
standardized order set. One of our sites told us you
know what, they actually worked with a pharmacy and got a
prefilled syringe of labatelol, so they didn’t have to
worrying about drawing it up at the last minute. So that was a great
process improvement. We also, again, the many
hospitals worked with their ED, worked with their
ability to communicate between the pharmacy,
ED to get medications and consults done
in a timely manner. And we improved the transition of blood pressure assessment
treatment from labor and delivery to postpartum
as well. We — initially many of
our RNs were reporting that they felt very
uncomfortable giving IV antihypertensives on the unit. And many of them still have in
their policies that they had to use cardiac monitoring. And so we were able to
work through those barriers and address those and
get that barrier removed. Again, many of these things — there’s just a whole list
of them, and I can’t even go into them now, but it’s
just been a fabulous process to see how creative people
have been, and we’ve been able to share them among
25 hospitals. So these are some
of the barriers, and I will end very
quickly with that, is that one of the things you
really have to be aware of is that data collection
is so time-consuming, and it really requires
administrative support. And what we’ve found
is many of our sites because we have been tweaking
our measures over this year of the collaborative and have
had — asked them to go back in and reenter their data, it has
been a huge burden on our sites, and there’s many
coding problems that — work chart coding of not only
hypertension and preeclampsia, but also, you know,
written in their chart if they’re doing a hand
review of the chart. They’re not seeing
those key words. And so we have a huge problem
with coding in our state, and I’m sure this is probably
translated throughout the rest of the country, lots of missing
under coding of preeclampsia. There’s a lot of
competing priorities now that hospitals are initiating. We have a lot of them that
are implementing Epic, and it’s causing
a lot of problems. There’s also limited
resources with staff, so getting somebody dedicated to collect the data
is very difficult. And if you don’t have an MD
champion to work with you, it’s very difficult to push
through a lot of the barriers. So our collaborative in
summary we have persevered through the measurement
remodeling. We do see improvements in our
outcomes and our processes. And we have — like I mentioned,
extended the collaborative through 2014 and we are now
planning a second collaborative now that we’ve kind of
gotten our measures in a spot where we think we’re really
looking at what we want to find out, and we’re going to
start that in January of 2015. So I’ll end here. If anyone has not downloaded the
toolkit, here’s the information. If you have any questions, I’m
more than happy to help you out. It has been, like I said, a
wonderful experience for all of us, and thank you so much.>>Thank you so much, Nancy. It was an excellent
presentation. At this time we will open
the lines for questions. Operator?>>Yes, ma’am, thank you. We’ll now begin today’s
question and answer session. If you’d like to ask a
question, please press “star 1” at this time, and record your
first and last name clearly when prompted so that I may
introduce your question. To withdraw any question,
you may press “star 2.” Once again, if you’d
like to ask a question, please press “star 1.” One moment please while I wait for our first questions
to arrive. [ Silence ]>>In the meantime, I
actually have a question — this is Keba, a question
for both speakers. When you’re looking at severe
morbidity or preeclampsia, what exactly in terms of the
outcomes are you looking at, other than — because
I know you excluded — in California you excluded
hemorrhage and transfusion, what exactly are
you looking for?>>Well, this is Nancy, and we actually used the
severe morbidities that were in the Kuklina 2009 paper that
includes acute renal failure, pulmonary edema, adult
respiratory, or ARDS, cerebral vascular
disorders, DIC, and we included actually
abruption. So we kind of have a
list of ICD 9 codes of those severe morbidities that
we are asking our collaborators to — that any — in
numerators, excuse me, anybody with those ICD 9
diagnoses would be included in the severe morbidity measure. We have it listed out
in our measurement grid.>>In New York State
we use the same paper to classify ours,
so it’s the same.>>Okay. [ Silence ] Believe there are some
questions on the line?>>Yes; our first question
comes from Ann Burke. Your line is now open.>>Hi, thank you. Thank you so much
for the presentation. When I checked the
website maybe 2 weeks ago, the toolkit was still restricted
to the member hospitals within the California
Collaborative. Is that still true, and if so
do you have any anticipated date when it might be
available to others?>>It actually was formally
released on January 16th, and it is available to anyone,
so it’s no longer restricted to our preeclampsia
collaborative. So when you log onto
the cmqcc.org site, you’ll see in the
left-hand column it will say “preeclampsia toolkit.” And if you click on that, it
will walk you through and just to go ahead and download it. So there should not be
any problems at all, and if you are having them,
will you please email me and I will help you get
that, because it’s available to anyone now, not
just our sites.>>This is for Zsakeba, when you
actually go for that toolkit, it does require you
to enter your email, I think some information
for them to — in order to download it.>>Yes, you’re right, Keba. Thank you for that. [ Silence ]>>And we’ll take
our next question at this time from Verda Gaines. Your line is now open.>>My question is, how are
you involving community-based and spiritual-based
organizations who are taking part in hospital,
clinic and community work groups and taskforces to address
this prenatal infant mortality morbidity problem? [ Silence ] Did you hear?>>Yeah. In New York
State we have a system of regionalization. And we’ve recently funded some
projects that in the region have to partner not only with
the highest level of care, so we have our regional
perinatal centers, which are level 4, and
their affiliated hospitals, but they also have to bring
in community partners. We have perinatal networks, and we have community health
workers, which are a big part of educating people, you know,
prior to coming to a facility. So we want to increase the
knowledge in the community. So we are working with — each
of these regions could decide who needed to be at the
table to do the best work. So they would bring in
all of these partners at the community level
to work with them.>>Thank you.>>Today’s next question comes
from Marsella Reid-Warren. Your line is open. [ Silence ]>>Hello?>>Hello. We can hear you.>>Okay, I’m sorry. I thought — I had my
— I couldn’t get it. Okay. Well, I’m currently
a working OB case manager, but I still per diem
in the labor unit. I’ve done it for 15 years
working labor and delivery. And it’s been a little
different going in per diem. I didn’t know if you
had a suggestion on how to approach management regarding
when you’re working with staff who I’ve seen where the blood
pressures are not being done appropriately, or you’re
assisting another nurse and you notice that they’re
not doing it appropriately, and they’re getting
incorrect blood pressures, and then when you assess it’s
different, but they don’t want to address it because
they want to do it on the side and get normal. What would be the approach
to address those issues when working with staff and
you know they’re not doing it appropriately?>>Well, most of our hospitals
actually made it mandatory for all of their nursing staff
to either attend an in-service, or they all — some of them put
together a pretty quick little module that they required
all of their staff to do it so that everybody
was on the same page. And you know what happens a
lot of times that you’ll see in a lot of the situations
that I’ve mentioned, is that hospitals and people — providers get into that
normalization of deviance, in that, you know, they get
away with things so many times that it’s very difficult
to get them to change, because they just don’t see
any adverse effects of it. So it was really an eye-opener
was we talked about this, and many of the nurses
kind of, you know, held up their hand
halfway like, “Oh my gosh, I didn’t even think about, you
know, that there’s a difference when you change positions, and how important it
is to be consistent.” So I think that that
really is an easy way to do it is just you can create
a very quick little PowerPoint or a, you know, module that you
can require all staff to do — to complete, to just
emphasize the main points. And I think if you look at
the chapter that we have in the toolkit, you can
pretty much just pull out the key points
and, you know, just have people
review it, and show it. What we’ve found, though, what’s huge was many hospitals
don’t have the right sized cuffs for the size of the
women that we have. And, you know, many
hospitals said, “You know, we have a hard time
even finding a cuff, let alone different sizes.” So that was a key item also is
that, you know, hospitals need to make sure that they have
their units stocked with, you know, all different
sized cuffs. And you even need to
have a pediatric cuff, because we found that, you
know, when we were kind of just doing it
for a skills day, that many of their little Asian
women needed a pediatric cuff, that even a standard
cuff is too big for them. And certainly, you know, our growing obese population you
need to have the large cuffs, and you need to have
alternatives as far as where you can place the cuffs if you can’t get an accurate
blood pressure on their arm, such as their calf
or their thigh. So we have a little
paragraph on dealing with that in the toolkit as well. But that’s another huge issue
is having not only the right consistency and position,
but also the right equipment, and recognizing that, you know, an auto cuff can alter
your blood pressures by up to 10 millimeters of mercury by using automated
blood pressure cuff, versus old-fashioned
cuff with a stethoscope. [ Silence ]>>Thank you very much.>>We’ll take [overlapping] — I’m sorry, we’ll take our next
question from Barbara Greer.>>Yes, hi, I do apologize. I wasn’t able to enter
until about 7 minutes after the webinar started,
so now I have 2 questions; the first being, “Is any of this
information broken down by race, and ethnicity, and age?” And then the second
question is, “Is it possible to get the recording, or at the
very least the PowerPoint slides of this presentation?” [ Silence ]>>Yes; this is Nancy. Our slides that we
have for the toolkits, once you download the
toolkit, you will have access to the whole slides
for the toolkit that you can share with anyone.>>Nancy, I think she’s
referring to the slides for the presentation; is
that correct, Barbara?>>Yes.>>Yes.>>This presentation,
not the toolkit.>>Okay, I’m sorry. At this time I forgot to
remind our participants that we do have handouts for the
slides for this presentation. If you look at the upper
right-hand side of your screen, there is a small icon with several pages,
little white pages. If you click on that icon
and select “upload” — select the files you want,
which are 2 handouts available, and click “upload,” you’ll
be able to get the handouts from today’s presentation. We’ll also send the handouts
with the evaluation that will go out after this presentation
as well. And the recording of this
presentation will be made available on our website.>>Okay, thank you.>>I’m sorry, back
to the speakers.>>That answers my
first question. [Laughs]>>And to address your question as to whether we’d break
our information up by race, ethnicity, and that,
yes, we do typically. For this, you know,
we didn’t include all that because it was a
briefer presentation. But we look at this
in that lens.>>Okay.>>And we do as well
in California. We have all that
information as well.>>And will that information
be available in the toolkit?>>It — let’s see, I
don’t think it’s actually in the toolkit, but certainly
if you want to email me, I can provide it for you. I mean, interestingly
I can just say overall that for our population the
Hispanics had the highest rates of preeclampsia.>>Okay.>>And the highest rates of maternal death
from preeclampsia.>>Okay, thank you.>>But I can give you more
detail if you want to look at it compared to all
other ethnic groups. I can — I would be
happy to do that.>>Thank you.>>Yes.>>At this time there
are no further questions in queue from the phone lines.>>I actually have — this
is Keba Henderson again. I have another question. You mentioned, Nancy, toward
the end of your presentation that you all are also
looking into balancing measure of low blood pressures
less than 80, and you said you have additional
information regarding that. Could you please
fill us in on that?>>Yes, absolutely. So one of the things that came
out of, again, we were hearing from a lot of our
sites that many of the providers were
uncomfortable giving antihypertensives to patients
who, you know, were in labor because of the whole notion
about causing the blood pressure to bottom out, and the fetal
heart rate to deteriorate. So we decided that to really
look at that is there any valid, you know, validity to that, because there really are no
studies that look at that. We added a balancing
measure of, you know, so that anytime they treated
a severe range blood pressure with IV labetalol, or
hydralazine, we asked them to let us know if the diastolic
blood pressure dropped below 80 by hitting yes, or
no, and if it was yes, were there any significant
fetal heart rate changes that prompted intervention? And then the final question
was if they answered yes, did it require an
emergent delivery? To really help us see that is
this a valid fear that a lot of our providers were saying
that kind of held them back from giving antihypertensives. And what we found is
that there is actually a significant number. Now, I have to pull —
I don’t have it with me, but there was actually, you
know, maybe 40% or so — just a ballpark figure, that actually did have diastolic
blood pressures below 80 after giving antihypertensives
— and we did it within an hour of giving antihypertensives, were there a diastolic
to look at? But out of those there was only
really 1 out of all of those that had that low diastolic that
required an emergent delivery. And, you know, of course there’s
a lot of variables in that. I mean, we don’t know if it was
specifically related to the fact that the blood pressure
dropped, but most of them even with the diastolic below 80
there was no significant fetal heart rate changes. So we had one of our sites,
led by Sarah Kilpatrick at Cedars-Sinai, they’re
actually doing a study, much more in-depth study
looking at that very issue, and they’re actually looking
at it from the perspective of, “We know that, you know, it probably makes a
difference whether or not they’ve had how
many doses they’ve had on the algorithm of
antihypertensives.” So there — we’re going to have
a lot more robust data once they finish that study. But initially it does not
appear to really have an impact on the fetal heart rate.>>Thank you. [ Silence ] Are there any further questions?>>No, ma’am; there
are no questions in the queue at this time.>>Okay; since there are
no further questions, I would like to thank Marilyn
Kacica and Nancy Peterson for giving us excellent
presentations of quality improvement efforts to address hypertensive
disorders of pregnancy. We would also like to thank
all of you for participating in this webinar, and invite
you to provide feedback about this presentation and
this webinar series as a whole. We will be contacting
you after this webinar by email for your input. We hope that our webpage and this webinar series
will facilitate exchange of information and provide — and promote visibility of perinatal quality improvement
activities throughout the country. We encourage you, again,
to visit our webpage at http://www.cdc.gov/
reproductivehealth/ MaternalInfanthealth/ PQC.htm
to learn more about CDC support of perinatal quality
improvement collaboratives. You can also contact
us at the DRH info link at the bottom of that webpage. Thank you again, and have
a wonderful afternoon. This ends today’s
webinar conference.


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