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