preeclampsia: improving care in ca – missouri march of ...apr 18, 2014 · preeclampsia:...
Post on 30-May-2020
0 Views
Preview:
TRANSCRIPT
Preeclampsia: Improving Care in CA – Missouri March of Dimes/HEN April 18, 2014 Nancy Peterson RNC, PNNP, MSN Clinical Program Manager, CMQCC Director of Perinatal Outreach Stanford University
Improving Health Care Response to Preeclampsia: A
California Quality Improvement Toolkit
Funding for the development of this toolkit was provided by: Federal Title V block grant funding from the California Department of Public Health; Maternal, Child and Adolescent Health Division and Stanford University.
2
Development of the California Toolkit ‘Improving Health Care Response to Preeclampsia’ was funded by the California Department of Public Health (CDPH), Center for Family Health, Maternal Child and Adolescent
Health (MCAH) Division, using federal Title V MCH funds.
Preeclampsia Task Force Members Maurice Druzin, MD – Stanford Elliott Main, MD – CMQCC Barbara Murphy, RN – CMQCC Tom Archer, MD – UCSD Ocean Berg, RN, CNS – SF General Hospital Brenda Chagolla, RNC, CNS – UC Davis Holly Champagne, RNC, CNS – Kaiser Meredith Drews – Preeclampsia Foundation Racine Edwards-Silva, MD – UCLA Olive View Kristi Gabel, RNC CNS – RPPC Sacramento Thomas Kelly, MD – UCSD
Larry Shields, MD – Dignity Health Nancy Peterson, RNC, PNNP – CMQCC Christine Morton, PhD – CMQCC Sarah Kilpatrick, MD – Cedars Sinai Richard Lee, MD – Univ. of Southern California Audrey Lyndon PhD, RNC – UC San Francisco Mark Meyer, MD – Kaiser SD Valerie Cape – CMQCC Eleni Tsigas – Preeclampsia Foundation Linda Walsh, PhD, CNM – UC San Francisco Mark Zakowski, MD – Cedars Sinai Connie Mitchell, MD, MPH – CDPH - MCAH
3
n The incidence of preeclampsia has increased by 25% in the United States during the past two decades.
n Worldwide Preeclampsia is a leading cause of maternal and perinatal morbidity and mortality, with an estimated 50,000-60,000 preeclampsia-related deaths per year worldwide.
Ref: ACOG – HIP, 2013
16
18
16
13
9 10
8
1011
14
9
12
78 8
1515
99
101110
6666
10
9
11
111111
87
10
11
15
12
17
12
21
0
5
10
15
20
25
1970 1975 1980 1985 1990 1995 2000 2005 2010
HP Objectives – Maternal Deaths (<42days postpartum) per 100,000 Live Births
Mat
erna
l Dea
ths
per 1
00,0
00 L
ive
Birt
hs
ICD-10 codes
ICD-8 codes
ICD-9 codes
Maternal Mortality Rate, California Residents: 1970-2010
SOURCE: State of California, Department of Public Health, California Birth and Death Statistical Master Files, 1970-2010. Maternal mortality for California (deaths ≤ 42 days postpartum) was calculated using the ICD-8 cause of death classification for 1970-1978, ICD-9 classification
for 1979-1998 and ICD-10 classification for 1999-2010. Healthy People Objectives: HP2000: 5.0 deaths per 100,000 live births; HP2010: 3.3 deaths, later revised to 4.3 deaths per 100,000 live births, and; HP2020: 11.4 deaths per 100,000 live births. Produced by California
Department of Public Health, Center for Family Health, Maternal, Child and Adolescent Health Division, December, 2012.
California Pregnancy-Associated Mortality Review (CA-PAMR) Quality Improvement Review Cycle
1. Identification of cases
2. Information collection, review by multidisciplinary
committee
3. Cause of Death, Contributing Factors and Quality Improvement (QI) Opportunities identified
4. Strategies to improve care and reduce
morbidity and mortality
5. Evaluation and Implementation of QI strategies and
tools
Toolkits: • Hemorrhage • Preeclampsia • Cardiovascular
(in development)
CA-PAMR Causes of Death (Top 5), 2002-2004
Grouped Cause of Death, per CA-PAMR Committee
Pregnancy-Related Deaths N (%)
Cardiovascular disease 29 (20) Cardiomyopathy 19 (13) Other cardiovascular 10 (7)
Preeclampsia/eclampsia 25 (17) Obstetric hemorrhage 16 (11) Amniotic fluid embolism 15 (10) DVT/ PE 15 (10)
Other 45 (31) TOTAL 145
1.6 deaths /100,000 live births
CA-PAMR: Chance to Alter Outcome Grouped Cause of Death; 2002-2004 (N=145)
Grouped Cause of Death Chance to Alter Outcome Strong / Good (%)
Some (%)
None (%)
Total N (%)
Obstetric hemorrhage 69 25 6 16 (11) Deep vein thrombosis/
pulmonary embolism 53 40 7 15 (10)
Sepsis/infection 50 40 10 10 (7) Preeclampsia/eclampsia 50 50 0 25 (17) Cardiomyopathy and other cardiovascular causes 25 61 14 28 (19)
Cerebral vascular accident 22 0 78 9 (6)
Amniotic fluid embolism 0 87 13 15 (10) All other causes of death 46 46 8 26 (18) Total (%) 40 48 12 145
400-500x
Serious Morbidity 3400/year
Maternal Morbidity and Mortality: Preeclampsia
40-50x
Near Misses: 400/yr (ICU admissions)
Preeclampsia Related Mortalities in CA
Source: 2007 All-California Rapid Cycle Maternal/Infant Database for CA Births: CMQCC
Maternal Hypertension in California, 1999-2005
Source: http://www.cdph.ca.gov/programs/mcah/Documents/MO-CAPAMR-TrendsinMaternalMorbidityinCalifornia-1999-2005-TechnicalReport.pdf
All maternal hypertension identified at time of hospitalization for labor and delivery (includes pre-gestational and gestational hypertension)
n Cohort of pregnancy-related deaths, N=145 ¨ 25 (17%) of deaths were grouped as “Preeclampsia/
Eclampsia” cause of death
n Over half of all pregnancy-related deaths had HTN diagnoses ¨ 50 (34%) had inpatient diagnosis of HTN ¨ 57 (39%) had any diagnosis of HTN (inpatient, prenatal,
preexisting)
Impact of Hypertension in CA-PAMR Cohort, 2002-2004
CA-PAMR Final Cause of Death Among Preeclampsia Cases, 2002-2004 (n=25) Final Cause of Death Number % Rate/100,000
Stroke Hemorrhagic Thrombo.c
16 14 2 -‐12.5%
1.0
Hepa0c (liver) Failure 4 16.0% .25 Cardiac Failure 2 8.0% Hemorrhage/DIC 1 4.0% Mul0-‐organ failure 1 4.0% ARDS 1 4.0%
How Do Women Die Of Preeclampsia in CA?
12
64% -87.5%
Cause of U.S. Maternal Mortality
n CDC Review of 14 years of coded data: 1979-1992 n 4024 maternal deaths n 790 (19.6%) from preeclampsia
MacKay AP, Berg CJ, Atrash HK. Obstetrics and Gynecology 2001;97:533-538
90% of CVA were from hemorrhage
Preeclampsia Mortality Rates in California and UK
Cause of Death among Preeclampsia Cases
CA-PAMR (2002-04) Rate/100,000
Live Births
UK CMACE (2003-05) Rate/100,000
Live Births
Stroke 1.0 .47 Pulmonary/Respiratory .06 .00
Hepatic .25 .19 OVERALL 1.6 .66
The overall mortality rate for preeclampsia in California
is greater than 2 times that of the UK, largely due to differences in deaths
caused by stroke. 14
Gestational Age Groups of CA-PAMR Deaths, 2002 to 2004
Early Preterm Birth Preeclampsia Deaths: 36% (n=9) were <34 weeks gestation
GESTATIONAL AGE GROUPS
2002-2004 CA-CA CA-PAMR PREECLAMPSIA DEATHS (N=25)
CA-PAMR NON-PREECLAMPSIA DEATHS
N (%) N (%)
<24 weeks 0 (0) 2 (2%)
24-31w6d 2 (8%) 13 (11%) 32-36w6d 12 (48%) -- 56% 29 (24%) -- 37%
>37 weeks 11 (44%) 76 (63%)
TOTAL 25 120
Contributing Factor (at least one factor probably or definitely contributed)
Preeclampsia N (%)
TOTAL N (%)
OVERALL 25 (100%) 129 (89%) PATIENT FACTORS 16 (64%) 104 (72%)
Underlying significant medical conditions 8 (50%) 40 (39%)
Delay or failure to seek care 10 (63%) 27 (26%)
Lack of understanding the importance of a health event
9 (56%) 16 (15%)
HEALTHCARE PROFESSIONALS 24 (96%) 115 (79%) Delay in diagnosis 22 (92%) 62 (54%)
Use of ineffective treatment 19 (79%) 48 (42%)
Misdiagnosis 13 (54%) 36 (31%)
Failure to refer or seek consultation 6 (25%) 26 (23%)
HEALTHCARE FACILITY 12 (48%) 72 (50%)
Factors Contributing to Pregnancy-Related Deaths, CA-PAMR 2002-2004
Preeclampsia Quality Improvement Themes
n Early recognition and response to clinical triggers of preeclampsia
n Importance of accurate BP measurement n Initiating antihypertensive meds early and
aggressively n Facilities and clinicians need to improve
coordination of care through multidisciplinary management, timely consultations and coordination within hospital units and between hospitals
ACOG and CMQCC Observations:
n Best practice recommendations are greatly needed to guide care of women with all forms of hypertension
n Identification of severe forms of preeclampsia continues to challenge clinicians.
n Improved patient education and counseling strategies are needed to convey more effectively the dangers of preeclampsia and hypertension and the importance of early detection to women with varying degrees of health literacy.
Obstet Gynecol 2013;122:1122-31
Ref: ACOG – HIP, 2013
Highlights and Clinical Pearls from…
Improving Health Care Response to Preeclampsia:
A California Quality Improvement Toolkit
Funding for the development of this toolkit was provided by: Federal Title V block grant funding from the California Department of Public Health; Maternal, Child and Adolescent Health Division and Stanford University
Toolkit Components n INTRODUCTION
¨ Clinical Pearls ¨ Classification and Diagnosis of Hypertensive Disorders of Pregnancy ¨ Suspected Preeclampsia Algorithm
n PATIENT CARE and TREATMENT RECOMMENDATIONS ¨ Obtaining an Accurate Blood Pressure Measurement ¨ Preeclampsia Early Recognition Tool ¨ Proteinuria ¨ Ante, Intra, Postpartum Nursing Management and Assessment of
Preeclampsia ¨ Nursing Management of Preeclampsia: Sample Policy and Procedure ¨ Outpatient Management of Preeclampsia ¨ Chronic Hypertension in Pregnancy ¨ Antihypertensive Agents in Preeclampsia ¨ Magnesium Sulfate ¨ Eclampsia Algorithm ¨ Teamwork and Communication
n PATIENT CARE and TREATMENT RECOMMENDATIONS (Cont.) ¨ Fluid Management in Preeclampsia ¨ Airway Management in Pregnant or Postpartum Women Having Seizures ¨ Severe Preeclampsia at <34 Weeks and Atypical Preeclampsia ¨ Consultation Triggers in Severe Preeclampsia for all OB Units ¨ Posterior Reversible Encephalopathy Syndrome (PRES)
n EMERGENCY DEPARTMENT and NON-OBSTETRICAL VISITS: ¨ Emergency Department Recognition and Treatment Focus on Delayed
Postpartum Preeclampsia and Eclampsia ¨ Evaluation and Treatment of Antepartum Preeclampsia/Eclampsia in the ED
Algorithm ¨ Evaluation and Treatment of Postpartum Preeclampsia/Eclampsia in the ED
Algorithm n EDUCATION AND PATIENT INFORMATION:
¨ Preeclampsia Signs and Symptoms Patient Education Checklist ¨ Prenatal and Postpartum Patient Counseling/or Education ¨ Discharge Information for Patients with Preeclampsia, HELLP Syndrome or
Eclampsia
Toolkit Components
Case Study n 31 y.o., G1 P0 at 36 4/7 weeks presented
to L&D with HTN (BPs ranging from 148/94 - 156/86)
n Induction of labor begun and when BP (in side lying position) was normal, induction discontinued and pt sent home
n Three days later (37 weeks) pt presented to L&D for scheduled follow up. BP 137/89 (semi-fowlers) and 121/76 (R. lateral) with trace of protein
n Sent home on bedrest
Case Study, Continued n Pt returned to same hospital at 42 wks for
“cervical ripening with hx of preeclampsia” n C/S at 8 cm for failure to progress n VS stable with BPs 111/65 – 152/97 n At 11 hrs post-op, BP 152/99 n On post-op day 2, she C/O severe
headache with BPs ranging from 176/86 – 240/120.
Case Study, Continued
n She coded within minutes and was transferred to a higher level of care secondary to acute coma with subdural hematoma and midline shift
n She died 18 hrs after transport on PP day 3
Quality Improvement Opportunities in Case Study
n This patient should have been delivered at 37-38 wks given hx of hypertension
n Missed triggers for HTN, headaches n More consistent and accurate BP
monitoring n Transfer to appropriate level of care when
indicated
Recommendations for Timing of Delivery
ACOG and CMQCC
n Gestational Hypertension: § BP>140/90 and < 160/110).
OR n Preeclampsia without severe features:
Delivery at 37 0/7 or at the time diagnosis after 37 weeks
Ref: Koopmans CM, et al. Induction of labour versus expectant monitoring for gestational hypertension or mild preeclampsia after 36 weeks gestation. (HYPITAT). Lancet 2009;374:979-88
Accurate Blood Pressure Measurement
n Correct cuff size (width of bladder 40% of circumference and encircle 80% of arm.
n Use a sitting or semi-reclining position with arm at heart level, legs uncrossed and feet flat.
Accurate Blood Pressure Measurement n If auscultating: use first audible sound
(Kortokoff I) as systolic pressure and use disappearance of sound (Kortokoff V) as diastolic pressure.
n If ≥140/90, repeat within 15 minutes and if still elevated, further evaluation is warranted.
n DO NOT reposition patient to either side to obtain a lower BP.
n Document BP, patient position and in which arm BP was taken.
Executive Summary: Hypertension in Pregnancy, American College of Obstetricians and Gynecologist, Obstet Gynecol 2013;122:1122-31. Copyright permission received.
Diagnostic Criteria for Preeclampsia
• New onset, persistent hypertension (≥ 15 min) • Systolic (≥160 mm Hg) or • Diastolic (≥ 110 mm Hg) hypertension
• In pregnant or postpartum women constitutes a hypertensive emergency* and it is inadvisable to wait 4 hours for treatment.
• BP above threshold after 15 min, should be treated with antihypertensive medication within 30-60 min.
Diagnosis 4 hours …..
*Emergent Therapy for Acute-Onset, Severe Hypertension With Preeclampsia or Eclampsia, ACOG Committee Opinion, # 514, December 2011
Key Clinical Pearl
Patients with vague symptoms of: Ø headache Ø abdominal pain Ø shortness of breath Ø generalized swelling Ø complaints of “I just don’t feel right”
should be evaluated for atypical presentations of preeclampsia or “severe features”
Sibai BM, Stella CL. Diagnosis and management of atypical preeclampsia-eclampsia. Am J Obstet Gynecol. May 2009;200(5):481 e481-487.
Key Clinical Pearl
An organized tool for identification of “clinical signs” or “triggers” that can aid providers in recognition and response
and avoid delay in diagnosis and treatment.
Joint Commission 2010 Sentinel Alert “Preventing Maternal Death”
Recommendations n “All birthing facilities should develop a
process for both the recognition and appropriate response in the event of a patient’s deteriorating condition with written criteria describing early warning signs and intervention strategies.”
n “Develop protocols and drills for recognizing, responding and treating preeclampsia.”
Sentinel Event Alert 2010, Issue 44, Jan 26, 2010
Preeclampsia Early Recognition Tool
Clinical Signs to Watch for:
10.30.13v1
Yogi Berra
“It ain’t over till it’s over.”
CMQCC/ACOG “It ain’t over till its over, 6 weeks postpartum”
Timing of Pregnancy-Related Deaths, CA-PAMR, 2002 to 2004
68%
8% 12%
4% 4% 0%
4%
0
10
20
30
40
50
60
70
80
0 1 2 3 4 5 6+
Number of weeks between baby's birth and maternal death
Percen
t Preeclampsia Deaths
88%
87%
Non-Preeclampsia Deaths (n=129)
Preeclampsia Deaths (n=25)
96%
89% 63%
17
7 1 1 1
10
0
10
20
30
40
50
60
70
0 1 2 3 4 5 6+
Perc
ent P
regn
ancy
-Rel
ated
Dea
th
Number of weeks between baby’s birth and maternal death
59
Eclampsia: Maternal-Perinatal Outcome: 254 Consecutive Cases over 12 years
n 83,720 deliveries
n One in Five (19%) did not have proteinuria
n One in Four (23%) did not have hypertension
Sibai BM. Eclampsia VI. Maternal-perinatal outcome in 254 consecutive cases. Am J Obstet Gynecol Sep 163(3):1049-1054; discussion 1054-1065 1990.
Eclampsia: Maternal-Perinatal Outcome: 254 Consecutive Cases over 12 years
n 73 (29%) occurred postpartum.
n Of the postpartum cases, more than half (55%) were at >48 hours
n Half had normal BP but all had a headache or visual complaints
Eclampsia VI. Maternal-perinatal outcome in 254 consecutive cases. Am J Obstet Gynecol Sep 163(3):1049-1054; discussion 1054-1065 1990.
CMQCC PREECLAMPSIA TOOLKIT
TREATMENT RECOMMENDATIONS
MANAGEMENT OF PREECLAMPSIA / ECLAMPSIA
ü Blood pressure control
ü Seizure prophylaxis/treatment
ü Delivery – 34, 37 weeks
ü Post partum surveillance/treatment
Reaffirmed 2012
Key Clinical Pearl
n The critical initial step in decreasing maternal morbidity and mortality is to administer anti-hypertensive medications within 60 minutes of documentation of persistent (retested within 15 minutes) BP ≥160 systolic, and/or >105-110 diastolic.
n Ideally, antihypertensive medications should be administered as soon as possible, and availability of a “preeclampsia box” will facilitate rapid treatment.
n In Martin et al., stroke occurred in: ¨ 23/24 (95.8%) women with systolic BP > 160mm Hg ¨ 24/24 (100%) had a BP ≥ 155 mm Hg
¨ 3/24 (12.5%) women with diastolic BP > 110mm Hg ¨ 5/28 (20.8%) women with diastolic BP > 105mm Hg
Martin JN, Thigpen BD, Moore RC, Rose CH, Cushman J, May. Stroke and Severe Preeclampsia and Eclampsia: A Paradigm Shift Focusing on Systolic Blood Pressure, Obstet Gynecol 2005;105-246.
Preeclampsia Toolkit BP Treatment Recommendations
Systolic ≥ 160
Diastolic ≥ 110
Repeat BP and treat within 60 minutes
(ideally ASAP)
≥155 ≥105-110 Alternative triggers*
Recommendations apply to all forms of hypertension:
Gestational HTN = Preeclampsia = Severe Preeclampsia
Hypertensive Medication Administration Oral versus IV
n First line therapy recommendations for treatment of critically elevated BP are with either IV labetalol or hydralazine.
n Treatment is needed in a patient without IV access oral nifedipine may be used (10 mg)
n Oral labetalol would be expected to be less effective due to its’ slower onset to peak and thus should be used only if nifedipine is not available in a patient without IV access.
ACOG Practice Bulletin #33, Reaffirmed 2012; ACOG Committee Opinion #514, 2012; Tuffnell D, Jankowitcz D, Lindow S, et al. BJOG 2005;112:875-880.
Key Clinical Pearl
n Magnesium sulfate therapy for seizure prophylaxis should be administered to any patients with:
¨ Severe Preeclampsia
¨ Preeclampsia with “severe features” i.e., subjective neurological symptoms (headache or blurry vision), abdominal pain, epigastric pain
¨ AND
¨ should be considered in patients with mild preeclampsia (preeclampsia without severe features)
Key Clinical Pearl
Algorithms for acute treatment hypertension and eclampsia should be readily available or preferably posted in
all clinical areas that may encounter pregnant women.
Emergency Medication Box for Severe Preeclampsia and Eclampsia
n Early follow-up for all patients with preeclampsia/eclampsia ¨ within 3-7 days if medication was used during labor and
delivery OR postpartum ¨ within 7-14 days if no medication was used
n Postpartum patients presenting to the ED with hypertension, preeclampsia or eclampsia should either be assessed by or admitted to an obstetrical service
Key Clinical Pearls
Key Clinical Pearls n Use of preeclampsia-specific checklists,
team training and communication strategies, and continuous process improvement strategies will likely reduce hypertensive related morbidity.
n Use of patient education strategies, targeted to the educational level of the patients, is essential for increasing patient awareness of signs and symptoms of preeclampsia.
Patient Education Materials
This and many other patient education materials can be ordered from www.preeclampsia.org/market-place
MANAGEMENT OF PREECLAMPSIA / ECLAMPSIA
ü Recognize and Don’t Ignore Clinic Signs
ü Treat and Control Blood Pressure
ü Magnesium for Seizure Prophylaxis/Treatment
ü Delivery – 34, 37 weeks
ü Postpartum Surveillance/Treatment
California Preeclampsia Collaborative Jan 2013-Aug 2014
Preeclampsia Collaborative Aims (Revised 9/2013)
n Aim 1: Reduce the rate of severe morbidi0es in women with severe preeclampsia or eclampsia or preeclampsia superimposed on pre-‐exis0ng HTN by 50% by Feb, 28, 2014
n Aim 2: Reduce the percentage of women (with severe preeclampsia or eclampsia or preeclampsia superimposed on pre-‐exis0ng HTN) with prolonged postpartum lengths of stay by X% by Feb 28, 2014
n AIM 3: Achieve 100% comple0on of required deliverables: Debrief, Policy & Procedure update.
Preeclampsia Collaborative: Measurement
n Outcome Measures ¨ Severe Morbidity among women with
Preeclampsia, Eclampsia, Preeclampsia superimposed on severe HTN
¨ Prolonged postpartum LOS (≥4 days vaginal, ≥6 days cesarean)
n Process Measures ¨ Appropriate Medical Management ¨ Debrief
n Balance ¨ Monitor for dBP <80
n FHR category change after treatment n Emergent delivery after treatment
55
Process Improvements
n Educational sessions for accurate BP measurement, and treatment thresholds
n Implementation of severe Pre-E order sets n Stocking prefilled emergency labetalol n Changed communication method between L&D
and pharmacy for emergency medications n Improved care transition of BP assessment/
treatment from L&D to postpartum
Process Improvements
n Removing barriers for IV antihypertensive administration by RN
n Improved communication between ED & OB n Continuation of magnesium during C/S n Changing postpartum follow-up or adding
home health visit n Debriefs becoming part of hospital culture
Barriers to implementation
n Data collection is time consuming and requires administrative support ¨ Poor chart documentation of HTN and PE ¨ Mis-and under-coding of preeclampsia
n Competing priorities n Limited resources n No MD champion
Preeclampsia Collaborative: Summary
n Collaborators persevered through “Measure Remodeling”! n We do see Improvements in Outcomes, Processes n Data Quality Improvement is a Continuing Goal! n Collaborative Extension: through August 2014 n 2nd Collaborative: January 2015 (register August 2014)
59
Getting The Job Done in Your Institution
n Establish tools / new recommendations n Establish champions and collaborators n Provide convincing rationale for change n Get providers to adopt the changes n Provide convincing evidence that the proposed
changes in clinical care improved outcome
n Distribute the convincing rationale and evidence
For More Information and to
Download the Toolkit
n Visit our website:
www.cmqcc.org n Or contact us:
info@cmqcc.org n Nancy Peterson peterson@cmqcc.org
Available online soon!!
Follow @CMQCC
Like CMQCC
top related