1 Illinois Maternal Hypertension Initiative Comprehensive Slide SetPresented by:

2 Acknowledgments This slide set was adapted from materials created by the following groups: FPQC Hypertension in Pregnancy Initiative CMQCC Preeclampsia Collaborative https://www.cmqcc.org/projects/past-projects/cmqcc-preeclampsia-collaborative ACOG DII (New York) Safe Motherhood Initiative https://www.acog.org/About-ACOG/ACOG-Districts/District-II/Safe-Motherhood-Initiative AIM Severe Hypertension in Pregnancy Bundle

3 Overview Background – HTN and QI AIM HTN Bundle: ReadinessAIM HTN Bundle: Recognition & Prevention AIM HTN Bundle: Response AIM HTN Bundle: Reporting & Systems Learning ILPQC Maternal Hypertension Initiative

4 Background Worldwide and in the United States, hypertension is one leading cause of pregnancy-related deaths (PRDs) before, during, or after delivery. Reports from North Carolina and California state that maternal deaths due to hypertension had significant prevention opportunities. (Berg, C. et al., 2005 & California Department of Public Health, 2011)

5 Maternal Morbidity and Mortality: PreeclampsiaAbout 8 Preeclampsia Related Mortalities/2007 in CA x Serious Morbidity: 3400/year (prolonged postpartum length of stay) 40-50x Near Misses: 380/year (ICU admissions) Based on analysis of data in the All-California Rapid Cycle Maternal/Infant Database for California births in 2007 – the extent of morbidity associated with preeclampsia is shown in this slide. There are approximately 8 deaths per year related to preeclampsia/eclampsia among CA women, but the rate of “near–miss” defined here as the number of ICU admissions is 380/yr and serious morbidities defined as prolonged postpartum length of stay is 3400/yr. Source: 2007 All-California Rapid Cycle Maternal/Infant Database for CA Births: CMQCC

6 Maternal Mortality

7 Cause of U.S. Maternal MortalityCDC Review of 14 years of coded data: 4024 maternal deaths 790 (19.6%) from preeclampsia 90% of CVA were from hemorrhage We have made no progress with regard to preventing maternal death from hemorrhagic cerebral vascular accidents. MacKay AP, Berg CJ, Atrash HK. Obstetrics and Gynecology 2001;97:

8 Prevalence – ACOG 2013 Incidence of preeclampsia has increased by 25% in the past 20 years Preeclampsia causes an estimated 60,000 maternal deaths yearly worldwide There are 50 –100 near misses for every maternal death Preeclampsia is a risk for future cardiovascular disease This slide provides some background on the importance of addressing Hypertension in Pregnancy. Read slide. For more detail, please see the FPQC Slide Set “HIP Mortality Data Background”

9 Distribution of Pregnancy- Related Causes of Deaths in IllinoisCause of Death Examples n % Vascular AFE, PE, cerebrovascular events, chronic HT 72 29.4% Cardiac Cardiomyopathy, heart disease, dysrhythmias 45 18.4% Hemorrhage Uterine rupture, atony, lacerations 35 14.3% Pre-eclampsia/ Eclampsia 18 7.3% Infection Puerperal, due to spontaneous AB 14 5.7% Cancer Breast, leukemia, lymphoma, melanoma 13 5.3% Pulmonary Pneumonia, asthma Other Psychiatric, anesthesia, hematologic, hepatic

10 Maternal Morbidity

11 Maternal Morbidity: Disparities in Illinois

12 ILPQC Maternal Hypertension InitiativeAim: Reduce the rate of severe morbidities in women with severe preeclampsia, eclampsia, or preeclampsia superimposed on pre-existing hypertension by 20% by December 2017 Approach: Established workgroup (1/2015), identify hospital teams (5/2016), implement evidence-based practices / protocols / AIM HTN Bundle (6/ /2017) OB Advisory Workgroup and HTN Clinical Leadership Team developed process/outcome measures, toolkit/education, data form and reports Input from IDPH SQC / PNAs / AIM Initiative / CA, NY, and NC Launched Wave 1 in January 2016 with 24 teams Launched Wave 2 on May 2, 2016 with 108 teams with over 200 participants on webinar!

13 Initiative Goals Early recognition of hypertension / preeclampsia triggers during pregnancy and postpartum period Reduce time to treatment of severe range blood pressure, >160/110(105) Provide patient education and appropriate discharge follow up Implementation of evidence based protocols Management of severe HTN, preeclampsia triggers, magnesium, expectant management vs delivery, postpartum management, eclampsia First and foremost, early recognition of hypertension in pregnancy is vital to managing the potential impacts. Blood pressure must be treated and guidelines have been established including treating within one hour of confirmed readings. Magnesium sulfate is not a blood pressure medication, it is for seizure control and is recommended for use in preeclampsia with severe features local protocols need to be developed and followed. Women with hypertension in pregnancy require close follow up and the full HIP toolkit provides recommendations for all women postpartum. There is a two-sided one page document in the HIP toolkit that you may find helpful in assuring that you utilize elements of the Patient Safety Bundle developed by ACOG, SMFM, AWHONN, and others for readiness, recognition, response and reporting.

14 ILPQC HTN Initiative Goal & MeasuresGoal: Reduce preeclampsia maternal morbidity IL Measure Type Goal Severe Maternal Morbidity No. of women with severe maternal morbidities (e.g. Acute renal failure, ARDS, Pulmonary Edema, Puerperal CNS Disorder such as Seizure, DIC, Ventilation, Abruption) / No. pregnant & postpartum women with new onset severe range HTN Outcome 20% reduction Appropriate Medical Management in under 60 minutes No. of women treated at different time points (30,60,90, >90 min) after elevated BP is confirmed / No. of women with new onset severe range HTN Process 100% Debriefs on all new onset severe range HTN* cases Discharge education and follow-up within 7-10 days for all women with severe range HTN, 72 hours with all women with severe range HTN on medications Severe range HTN: ≥160 systolic / ≥110(105) diastolic per hospital standard *New onset severe range HTN: first episode of persistent severe range HTN (lasting >15 minutes) in a hospitalization (ER, L&D, or other inpatient setting), can be chronic HTN, gestational HTN, preeclampsia and/or postpartum diagnosis.

15 Opportunities for Quality ImprovementEarly recognition of hypertension and response to clinical triggers of preeclampsia (pregnant and pp) Importance of accurate blood pressure measurement Initiating antihypertensive medications early and aggressively for BP >160/110(105) Coordination of care (L&D, PP, ED, ICU) and timely evaluations and consultations Postpartum follow-up and patient education

16 Where to start? Staff education and standardized BP measurementRapid access to medications IV treatment of BP’s ≥ 160mmHg systolic or ≥ 110(105) mmHg diastolic within min Uniform policy for magnesium sulfate Early postpartum follow-up Standardized postpartum patient educational materials.

17 Implementation of AIM Hypertension BundleILPQC Maternal Hypertension Initiative roll out will focus on implementation of the AIM Hypertension Patient Safety Bundle Drive quality improvement through the 4 domains/key drivers Readiness (every Provider and unit) Recognition & Prevention (every case of HIP) Response (every patient) Reporting & Systems Learning (every multidisciplinary team) Implementation of resources linked to bundle Visual aids, checklists, algorithm’s, protocols, etc. Education for physicians and nurses Key education topics and use of resources ILPQC Maternal HTN Quality Improvement Initiative has been approved to meet ABOG Part IV Improvement in Medical Practice MOC requirements for 2016 and 2017 for participating OB/GYN physicians

18 AIM Hypertension Safety Patient BundleReadiness (every Provider and Unit) Recognition & Prevention (every patient) Response (every case of HIP) Reporting/Systems Learning (every multidisciplinary team)

19 Hypertension Safety Patient BundleReadiness (every Provider and Unit) Standards for diagnostic criteria, early warning signs, monitoring and management/ treatment of preeclampsia w/ and w/o features (include policies, procedures, order sets and algorithms)

20 Readiness at Your HospitalStandardize preeclampsia diagnostic criteria Process flow Look at antepartum/postpartum, ED, and Triage Protocols reflect current standards / evidence Samples available Implementation Checklist Order sets AIM baseline survey

21 Updated Terminology and New Standards for Diagnostic Criteria

22 ACOG Executive Summary on Hypertension In Pregnancy, Nov 20131. The term “mild” preeclampsia is discouraged for clinical classification. The recommended terminology is: a. “preeclampsia without severe features” (mild) b. “preeclampsia with severe features” (severe) 2. Proteinuria is not a requirement to diagnose preeclampsia with new onset hypertension. 3. The total amount of proteinuria > 5g in 24 hours has been eliminated from the diagnosis of severe preeclampsia. 4. Early treatment of severe hypertension is mandatory at the threshold levels of 160 mm Hg systolic or 110 mm Hg diastolic. 5. Magnesium sulfate for seizure prophylaxis is indicated for severe preeclampsia and should not be administered universally for preeclampsia without severe features (mild).

23 ACOG Executive Summary on Hypertension In Pregnancy, Nov 20136. Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications. 7. Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension. 8. The postpartum period is potentially dangerous. Patient education for early detection during and after pregnancy is important. 9. Long-term health effects should be discussed. It should be noted however that the CMQCC Preeclampsia task force recommends that magnesium sulfate be considered for preeclampsia without severe features.

24 Terminology Previous Present Pregnancy Induced Hypertension (PIH)Mild and Severe Preeclampsia Hypertension in Pregnancy (HIP) Preeclampsia with or without severe features Preeclampsia with onset prior to 34 weeks is most often severe and should be managed at a facility with appropriate resources for management of serious maternal and neonatal complications.

25 Proteinuria 300 mg in a 24 hour period orProtein/creatinine ratio 0.3 (mg/dL/mg/dL) 1+ or more proteinuria by dipstick if above are not available The old 5 grams of protein has gone away . The amount of proteinuria does not correlate with outcome, or guide therapy

26 Delivery Management Induction of labor at 37 weeks is indicated for preeclampsia and gestational hypertension.

27 Postpartum Attention The postpartum period is potentially dangerous. Patient education for early detection of signs and symptoms of preeclampsia during and after pregnancy is important. Long-term health effects of preeclampsia should be discussed.

28 Updated Classification of Hypertension in PregnancyChronic (Preexisting) Hypertension Abnormal blood pressure predating pregnancy or before 20 weeks gestation Hypertension that predated the pregnancy Hypertension that develops before 20 weeks gestation and first trimester blood pressures are not known Gestational Hypertension Abnormal blood pressure first developing in pregnancy Hypertension that develops after 20 weeks gestation in a woman with previously normal blood pressure At least two measurements taken 4 or more hours apart If hypertension occurs before 20 weeks gestation and first trimester blood pressure measurements are normal, then consider early onset gestational hypertension Rule out preeclampsia

29 Updated Classification of Hypertension in PregnancyPreeclampsia Abnormal blood pressure as described in gestational hypertension plus proteinuria Greater than 300 mg total protein in a 24 hour collection Random urine protein (mg/dL) to creatinine (mg/dL) ratio of 0.3 1+ protein on urine dipstick if above quantifiable measures not available Severe features for gestational hypertension and preeclampsia* Systolic blood pressure greater than 160 mm Hg or diastolic blood pressure greater than 110 mm Hg (check blood pressure within 15 minutes to confirm since persistent elevation greater than 160 mm Hg or 110 mm Hg is a hypertensive emergency) CNS symptoms (generalized tonic clonic seizure, headache or visual disturbances) Pulmonary edema Platelet count less than 100,000/microliter Elevation serum transaminases more than 2 times over baseline or ALT greater than 70 Serum creatinine level greater than 1.1 mg/dL or doubling of serum creatinine HELLP syndrome

30 Updated Classification of Hypertension in PregnancySuperimposed preeclampsia Chronic hypertension with the development of preeclampsia Sudden increase in blood pressure that was previously controlled requiring escalation of blood pressure medication New onset proteinuria or sudden increase in proteinuria Development of any of the criteria listed under “severe features” Postpartum Hypertension New onset condition OR Secondary to persistent hypertension BP increases again 3-6 days postpartum Symptoms of preeclampsia or eclampsia, including stroke Can develop up to 4-6 weeks postpartum

31 Hospital Protocols, Algorithms, Order setsFacility-wide standard protocols with checklists and escalation policies for management and treatment of: severe hypertension eclampsia, seizure prophylaxis, and mag over-dosage postpartum presentation of severe hypertension/preeclampsia

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35 Readiness (every Provider and Unit)Recognition & Prevention (every patient) Standard protocol for measurement and assessment of BP, labs and urine protein for all pregnant and postpartum women Standard and timely response to maternal early warning (danger) signs including listening to and investigating patient’s symptoms, fetal condition and assessment of labs “The best way to diagnose preeclampsia is to listen to your patients.” ~ Dr. Baha Sibai

36 Importance of Obtaining Accurate Blood PressurePreeclampsia and preeclampsia with severe features are characterized by elevated blood pressure. Failing to accurately measure blood pressure in a consistent manner can lead to misdiagnosis, delays in treatment, worsening disease, increased morbidity and even death. Accurate blood pressure measurement is essential for clinical decision making Correct positioning of the woman Proper equipment (cuff sizes and shapes; calibrated readings) Hypertension in pregnancy is one of the leading causes of maternal mortality and morbidity. Having a standardized assessment of blood pressure is important to the early recognition and management of hypertension in pregnancy. Preeclampsia had the possibility of quickly becoming severe and resulting in seizures, strokes and other associated syndromes. In order to make good clinical decisions it is necessary to have accurate consistent assessments. To do this equipment must be appropriate in size and shapes of cuffs and well maintained.

37 Challenge #1: Proper positioning of the womanIf in bed: Semi-fowlers with the head of the bed elevated degrees; arm supported; legs uncrossed If sitting in chair: feet resting on the floor (not dangling) At least 5 minutes of rest before assessment Arm: Right arm preferred but either arm may be used and should be supported Cuff at heart level No talking : Systolic and diastolic BPs of hypertensive and normotensive patients increase with talking ***NOT lying down in bed*** The first challenge in determining accurate blood pressure is appropriate cuff size. 40 to 50% of the arm should be covered with the cuff. If too small the pressure measured is higher than actual pressure. If too large the measure is artificially lower. Both result in the potential for inaccurate diagnosis and possible poor outcomes for patients.

38 Challenge #2: Choose the Right Cuff SizeThe cuff bladder width should cover between 40-50% of the circumference of the arm. The lower cuff edge should be about 1 inch above the antecubital space Center the bladder over the brachial artery If the cuff is too small the blood pressure will be falsely higher if the cuff is too large the reading will be artificially lowered The first challenge in determining accurate blood pressure is appropriate cuff size. 40 to 50% of the arm should be covered with the cuff. If too small the pressure measured is higher than actual pressure. If too large the measure is artificially lower. Both result in the potential for inaccurate diagnosis and possible poor outcomes for patients.

39 Challenge #3: Choose the Right Cuff ShapeNot every woman has an upper arm shape that works with a rectangular cuff. Some women have an upper arm shape the is conical rather than cylindrical. Arm shapes vary greatly and an appropriate shape cuff must be used or again, the measures will not be accurate. There are rectangular and conical cuffs and these should be available for use on every unit.

40 Challenge #4: The Obese PatientUpper arm circumference > 50 cm Can use a thigh cuff if upper arm is long enough Measure forearm Choose cuff that covers 40% of circumference Inflate cuff and feel for radial pulse This method is not considered as accurate and should be used in circumstances when a proper cuff can’t be obtained. Obesity is a big challenge in clinical obstetric practice brining a variety of complications and concerns. Hypertension is one of the complications of obesity therefore accurate measures of blood pressure for obese women is essential. Depending on the length of the upper arm, a thigh cuff may be used, for upper arm circumference greater than 50 cm. The forearm may also be used with a cuff that covers 40% of the arm. Newer cuffs for radial measures are coming available but if they are not used and a cylindrical cuff is used instead it may not be as accurate.

41 Clinical Pearls Take time to use correct equipment and measure her armPosition the woman correctly Initial blood pressure should be assessed after the woman has been resting with minimal distraction for 5 minutes. BP ≥160/110(105) lasting for 15 minutes must be should in under minutes ≥ 90 diastolic 140 systolic OR Initial BP is ≥ Repeat blood pressure in 15 minutes Take in the same arm Do not reposition to side-lying ≥ 110(105) diastolic 160 systolic or Notify provider after first elevated BP Reassess after 15 minutes Activate treatment algorithms if remains ≥160/110(105) Evaluate for preeclampsia There are several key elements to accurate blood pressure. (read slide) Activate Severe HTN Treatment Algorithm

42 Appropriate Preeclampsia Evaluation

43 Key Clinical Pearl Patients presenting with vague symptoms of:headache abdominal pain shortness of breath generalized swelling 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 e

44 Laboratory Evaluation of PreeclampsiaInitial lab studies should include: CBC with platelet count AST, ALT, LDH Creatinine, Bilirubin, Uric acid, Glucose For women with acute abdominal pain, add: Serum amylase, lipase and ammonia Bilirubin comes on most liver function lab panels and is helpful in cases of severe HELLP syndrome and Acute fatty liver disease.

45 Diagnosis Criteria for PreeclampsiaThe new ACOG guidelines which will be published in Fall 2013, may eliminate proteinuria as a criterion for diagnosis of preeclampsia. Executive Summary: Hypertension in Pregnancy, American College of Obstetricians and Gynecologist, Obstet Gynecol 2013;122: Copyright permission received.

46 Diagnosis of Preeclampsia with Severe FeaturesTo make the diagnosis of severe PE, you need to have documented SBP of 160 or greater on two occasions 4 hrs apart. However in the acute onset of HTN above threshold 160/ it is unadvisable to wait 4 hrs for treatment. A BP should be repeated in 15 min and if still elevated above threshold, treat with antihypertensive medication within min. Executive Summary: Hypertension in Pregnancy, American College of Obstetricians and Gynecologist, Obstet Gynecol 2013;122: Copyright permission received.

47 Preeclampsia Early Recognition ToolThis is a tool that is designed to aid in the early recognition and response to a patient’s deteriorating condition as the disease process progresses in severity. The next slide is a continuation of this form with interventions based on the number of triggers.

48 Clinical Signs to Watch for:The hope is that this Early Recognition Tool can be incorporated into the maternal notes and can be initiated in prenatal clinics and utilized as vital sign documentation until discharge. The chart stays with the patient until discharge creating a visual trend of individual physiology and allows assessment and treatment based on what is abnormal for the patient.

49 Timing of Delivery Hypertension in PregnancyNot To Early….Not Too Late

50 Preeclamptic Balancing ActStroke Hemorrhage Renal Failure Hepatic Failure Subcapsular Hepatic Hematoma Pulmonary Edema Retinal detachment Placental Abruption Fetal and Maternal Death Etc… Prematurity ROP Sepsis NEC IVH CP RDS Etc… CMOP

51 When to Deliver Chronic HypertensionWith no additional maternal or fetal complications, delivery before 38 0/7 weeks not recommended With superimposed preeclampsia, follow preeclampsia recommendations Preeclampsia/Gestational Hypertension Without severe features: May expectantly manage until severe features present or 37 0/7 weeks With Severe Features Prior to viability- deliver May expectantly manage in appropriate setting until 34 weeks gestation, if maternal and fetal status stable American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol Nov;122(5):

52 Key Clinical Pearl In patients with preterm preeclampsia with severe features, the disease can rapidly progress to significant maternal morbidity and/or mortality. We must emphasize the fact that in patients with preterm preeclampsia the progression of disease is highly unpredictable and therefore the level of surveillance in these patients must be increased. We strongly recommend that all patients with new onset hypertension, new onset proteinuria or new onset symptoms under 34 weeks gestation, be admitted for a minimum 24 hour observation period. Serial blood pressure measurements and serial laboratory studies should be initiated to detect progression of disease and allow for ongoing fetal assessment. *Transfer to appropriate level of care if possible

53 Expectant Management of Pregnancies < 34 Weeks Gestation (From CMQCC Preeclampsia Toolkit, 2013)These tables describe the approach to preeclampsia with severe features < 34 wks. *Patients with eclampsia and visual disturbances should be evaluated in consultation with critical care medicine/neurology for the presence of Posterior Reversible Encephalopathy Syndrome (PRES). **Mental status changes in the presence of severe thrombocytopenia should be evaluated in consultation with hematology for Thrombotic Thrombocytopenic Purpura (TTP) and consideration for treatment or transfer to a center with treatment capacity should be given.

54 Management of Preeclampsia with Severe Features at Less Than 34 Weeks Gestation After Viability American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol Nov;122(5): NO EXPECTANT MANAGEMENT

55 Expectant Management of Preeclampsia with Severe Features at Less Than 34 Weeks Gestation American College of Obstetricians and Gynecologists, Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol Nov;122(5):

56 Initial 24-48 hours observationManagement of Suspected Severe Preeclampsia < 34 Weeks Gestation No contraindications to expectant management – Short Term Initial hours observation Initiate antenatal corticosteroids if not previously administered Initiate 24 hour urine monitoring as appropriate Ongoing assessment of maternal symptoms, BP, urine output Daily lab evaluation (minimum) for HELLP and renal function May observe on an antepartum ward after initial evaluation Proceed to delivery for: Recurrent severe hypertension despite therapy Other contraindications to expectant management Antenatal corticosteroid treatment completed: Expectant management not contraindicated Consider ongoing in-patient expectant management Adapted from Sibai BM. Evaluation and management of severe preeclampsia before 34 weeks’ gestation. American Journal of Obstetrics & Gynecology, September 2011, pg

57 Expectant management recommendations:Expectant Management in Pregnancies with Severe Preeclampsia < 34 Weeks Gestation Expectant management recommendations: With stable maternal/fetal conditions, continued pregnancy should be undertaken only at facilities with adequate maternal and neonatal intensive care resources Administer corticosteroids for fetal lung maturity benefit ACOG Executive Summary: Hypertension in Pregnancy. Obstet Gynecol 2013;122:

58 Management of Suspected Severe Preeclampsia < 34 Weeks GestationLong Term Management Consider ongoing, inpatient expectant management until 34 weeks or indication for delivery: Monitor vital signs frequently (at least each shift) At least daily maternal assessment for subjective symptoms of severe preeclampsia At least daily assessment of fetal well-being Serial evaluation for HELLP syndrome and of renal function Serial estimation of fetal growth and amniotic fluid volume Adapted from Sibai BM. Evaluation and management of severe preeclampsia before 34 weeks’ gestation. American Journal of Obstetrics & Gynecology, September 2011, pg

59 Indications for Delivery34 weeks gestation OR Any of the following: Uncontrolled hypertension despite therapy Recurrent symptoms such as headache, visual changes, RUQ pain Pulmonary edema Significant renal or hepatic dysfunction HELLP Syndrome or Disseminated Intravascular Coagulation Eclampsia Abruptio placenta Non reassuring fetal status: growth restriction, oligohydramnios, or abnormal fetal testing

60 Management of Gestational Hypertension orPreeclampsia without Severe Features

61 Preeclampsia: Outpatient ManagementMaternal stability BP in the non-severe range Gestational age < 37 weeks (At 37 weeks delivery should be considered) No indicators of severe features of preeclampsia None of the following maternal symptoms: Headache, visual disturbances, abdominal pain, gastrointestinal symptoms No evidence of hemolysis In essence a near normal laboratory assessment

62 Preeclampsia: Outpatient ManagementFetal stability Appropriate fetal growth Reassuring antenatal fetal testing Normal amniotic fluid volume Ability to be followed as an outpatient Communicative and reliable patient Patient can check BP at home Twice weekly assessment in office: Maternal blood pressure Laboratory assessment for indicators of worsening disease (creatinine, liver function, platelets) Fetal testing including amniotic fluid assessment Periodic ultrasound assessment of fetal growth

63 Readiness (every Provider and Unit)Recognition & Prevention (every patient) Response (every case of HIP) Process for timely triage and evaluation of pregnant and postpartum women with hypertension including emergency department and outpatient

64 Key Clinical Pearl Controlling blood pressure is the optimal intervention to prevent deaths due to stroke in women with preeclampsia. Over the last decade, the UK has focused QI efforts on aggressive timely treatment of both systolic and diastolic blood pressure and has demonstrated a significant reduction in deaths.

65 Key Clinical Pearl 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 > diastolic. Ideally, antihypertensive medications should be administered as soon as possible, and availability of a “preeclampsia box” will facilitate rapid treatment. 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;

66 Need To Treat* BP ≥ 160/110(105) *BP persistent 15 minutes, activate treatment algorithm with IV therapy ASAP, < minutes

67 Hypertensive Medication Administration Oral versus IVFirst line therapy recommendations for acute treatment of critically elevated BP in pregnant women [>160/110(105)] are with either IV labetalol or hydralazine. In the event that acute treatment is needed in a patient without IV access oral nifedipine may be used (10 mg) and may be repeated in 30 minutes. PO (oral) nifedipine appears equally as efficacious as IV labetalol in correcting severe BP elevations. Oral labetalol would be expected to be less effective in acutely lowering the BP 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:

68 Antihypertensive Therapy First line agentsIV Labetalol (Normadyne) Beta blocker (some alpha) Caution with heart rate < 60, congenital heart failure, AV heart block or asthma Can repeat after 10 minutes (Hydralazine) IV Apresoline Vasodilator Watch for rebound tachycardia or hypotension Caution with Heart rate > 100, recent stroke, severe mitral valve disease Can repeat after 20 minutes PO Nifedipine* (Procardia) Calcium channel blocker Caution with heart rate > 100, severe aortic stenosis, recent MI, cardiogenic shock. Can repeat after 30 minutes *If IV access unavailable

69 ACOG protocol Standing Order (Labetalol)Labetalol 20 mg IV over 2 minutes Recheck in 10 min If still elevated, labetalol 40 mg IV over 2 min If still elevated, labetalol 80 mg IV over 2 min Seek consultation MFM, Critical Care, Anesthesia, Internal medicine If still elevated, Repeat labetalol 80mg over 10 minutes to achieve total dosage of 220mg (includes all previous administrations) Switch to hydralazine 10 mg IV over 2 min Recheck in 20 min 1. Notify physician if systolic BP measurement is greater than or equal to 160 mm Hg or if diastolic BP measurement is greater than or equal to 110 mm Hg. 2. Institute fetal surveillance if undelivered and fetus is viable. 3. Administer labetalol (20 mg IV over 2 minutes). 4. Repeat BP measurement in 10 minutes and record results. 5. If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely. 6. Repeat BP measurement in 10 minutes and record results. 7. If either BP threshold is still exceeded, administer labetalol (80 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely. 8. Repeat BP measurement in 10 minutes and record results. 9. If either BP threshold is still exceeded, administer hydralazine (10 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely. 10. Repeat BP measurement in 20 minutes and record results. 11. If either BP threshold is still exceeded, obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care specialists. 12. Give additional antihypertensive medication per specific order. Target B/P 140 to <160 or

70 ACOG Protocol (Labetalol)Notify physician if systolic BP measurement is greater than or equal to 160 mm Hg or if diastolic BP measurement is greater than or equal to 110 (105) mm Hg. Institute fetal surveillance if undelivered and fetus is viable. Administer labetalol (20 mg IV over 2 minutes). Repeat BP measurement in 10 minutes and record results. If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely. If either BP threshold is still exceeded, administer labetalol (80 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely. If either BP threshold is still exceeded, administer hydralazine (10 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely. Repeat BP measurement in 20 minutes and record results. If either BP threshold is still exceeded, obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care specialists. Give additional antihypertensive medication per specific order.

71 ACOG protocol Standing Order (Hydralazine)Hydralazine 5 or 10 mg IV over 2 minutes Recheck in 20 min If still elevated, hydralazine 10 mg IV over 2 min Recheck 20 min If still elevated, labetalol 20 mg IV over 2 min Recheck in 10 min If still elevated, labetalol 40 mg IV over 2 min Emergency consults: MFM and anesthesia 1. Notify physician if systolic BP is greater than or equal to 160 mm Hg or if diastolic BP is greater than or equal to 110 mm Hg. 2. Institute fetal surveillance if undelivered and fetus is viable. 3. Administer hydralazine (5 mg or 10 mg IV over 2 minutes). 4. Repeat BP measurement in 20 minutes and record results. 5. If either BP threshold is still exceeded, administer hydralazine (10 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely. 6. Repeat BP measurement in 20 minutes and record results. 7. If either BP threshold is still exceeded, administer labetalol (20 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely. 8. Repeat BP measurement in 10 minutes and record results. 9. If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes) and obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care specialists. 10. Give additional antihypertensive medication per specific order. Target B/P 140 to <160 or

72 ACOG Protocol (Hydralazine)Notify physician if systolic BP is greater than or equal to 160 mm Hg or if diastolic BP is greater than or equal to 110 (105) mm Hg. Institute fetal surveillance if undelivered and fetus is viable. Administer hydralazine (5 mg or 10 mg IV over 2 minutes). Repeat BP measurement in 20 minutes and record results. If either BP threshold is still exceeded, administer hydralazine (10 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely. If either BP threshold is still exceeded, administer labetalol (20 mg IV over 2 minutes). If BP is below threshold, continue to monitor BP closely. Repeat BP measurement in 10 minutes and record results. If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes) and obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care specialists. Give additional antihypertensive medication per specific order.

73 ACOG protocol Standing Order (Oral Nifedipine)Nifedipine 10 mg PO (never crush or give SL) Recheck in 20 min If still elevated, nifedipine 20 mg PO Recheck 20 min If still elevated, nifedipine 40 mg PO Emergency consults: MFM and anesthesia, critical care or internal medicine If still elevated, switch to labetalol or hydralazine protocol 1. Notify physician if systolic BP is greater than or equal to 160 mm Hg or if diastolic BP is greater than or equal to 110 mm Hg. 2. Institute fetal surveillance if undelivered and fetus is viable. 3. Administer nifedipine 10 mg PO 4. Repeat BP measurement in 20 minutes and record results. 5. If either BP threshold is still exceeded, administer nifedipine 20 mg PO. If BP is below threshold, continue to monitor BP closely. 6. Repeat BP measurement in 20 minutes and record results. 7. If either BP threshold is still exceeded, administer nifedipine 20 mg PO. If BP is below threshold, continue to monitor BP closely. 8. Repeat BP measurement in 20 minutes and record results. 9. If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes) and obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care specialists. 10. Give additional antihypertensive medication per specific order.

74 ACOG Protocol (PO Nifedipine)Notify physician if systolic BP is greater than or equal to 160 mm Hg or if diastolic BP is greater than or equal to 110 (105) mm Hg. Institute fetal surveillance if undelivered and fetus is viable. Administer nifedipine 10 mg PO Repeat BP measurement in 20 minutes and record results. If either BP threshold is still exceeded, administer nifedipine 20 mg PO. If BP is below threshold, continue to monitor BP closely. If either BP threshold is still exceeded, administer labetalol (40 mg IV over 2 minutes) and obtain emergency consultation from maternal–fetal medicine, internal medicine, anesthesia, or critical care specialists. Give additional antihypertensive medication per specific order.

75 Anti-Hypertensive Medications for Chronic HypertensionAgent Initial dosing Frequency Total maximal daily dose Labetalol* 200 mg bid Q 12 hours to Q 8 hours 2400 mg Nifedipine long acting 30 mg daily Daily 120 mg Methyldopa** 250 mg bid Q 12 hours to Q 6 hours 3000 mg In the HIP toolkit we provide several tables of medication for you to utilize in planning for first and second line treatment, this is a sampling of the meds used for chronic hypertension.

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80 Magnesium Therapy: Key Clinical PearlMagnesium sulfate therapy for seizure prophylaxis should be administered to any patients with: Preeclampsia with “severe features” i.e., subjective neurological symptoms (headache or blurry vision), abdominal pain, epigastric pain, OR BP > 160/110 Eclampsia Should be considered in patients with preeclampsia without severe features

81 Recommendations for Women Who Should Be Treated With MagnesiumPreeclampsia without severe features Preeclampsia with Severe Features Eclampsia ACOG ** X NICE SOGC X* CMQCC WHO ACOG did not recommend the use of magnesium sulfate in the case of mild preeclampsia because 109 patients had to be treated to prevent one case of eclampsia.  In the case of severe preeclampsia, 63 patients needed to be treated to prevent eclampsia, and the use of magnesium sulfate was recommended. **ACOG Executive Summary, 2013: for preeclampsia without severe features, it is suggested that magnesium sulfate not be administered universally for the prevention of eclampsia. * Should be considered: Numbers needed to treat (NNT) = 109 for “mild”, 63 for “severe”

82 Late Postpartum Eclampsia>48 hours following delivery, up to 4 weeks PP Accounts for approximately 15% of cases of eclampsia 63% had no antepartum hypertensive diagnosis The magnitude of blood pressure elevation does not appear to be predictive of eclampsia The most common presenting symptom was headache, which occurred in about 70% of patients; other prodromal symptoms included shortness of breath, blurry vision, nausea or vomiting, edema, neurological deficit, and epigastric pain Al-Safi Z, Imudia A, Filetti L, et al. Delayed Postpartum Preeclampsia and Eclampsia. Obstet Gynecol. 2011;118(5):

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85 Patient Education Postpartum/ discharge protocols should include:Management and verification of postpartum follow-up & BP check within 7 to 10 days post-discharge Standardize discharge patient education for women with preeclampsia and/or severe range HTN Discharge instructions to include warning signs of preeclampsia for ALL postpartum patients Support/communication plan for patients, families, and staff for ICU admissions and serious complications of severe hypertension

86 Materials for Prenatal & Postpartum Patient Education“7 Symptoms Every Pregnant Woman Should Know” video available in English and Spanish on YouTube™ Other patient education materials include: Brochures Magnets Videos Poster (avail. early 2016) Providers can order at: preeclampsia.org/store You W, et al. Improving patient understanding of preeclampsia: a randomized controlled trial. Am J Obstet Gynecol 2012.

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89 Key Strategies to Improve Response

90 Rapid access to medications used for severe hypertension:medications should be stocked and immediately available Include brief guide for administration & dosage. System plan for escalation for maternal hypertension, obtaining appropriate consultation, and maternal transport, as needed

91 Facility-wide standard protocols with checklists and escalation policies for management and treatment of: severe hypertension eclampsia, seizure prophylaxis, and mag over-dosage postpartum presentation of severe hypertension/preeclampsia

92 Minimum requirements for protocol:Notification of primary physician or primary care provider if systolic BP ≥160 or diastolic ≥110 for 2 measurements within 15 min After second elevated reading, treatment should be initiated ASAP (within 60 min of verification) Includes onset and duration of magnesium sulfate therapy Appropriate labs sent and fetal assessment

93 Minimum requirements for protocol (cont):Includes escalation measures for those unresponsive to standard treatment Describes management and verification of follow-up within 7 to 14 days postpartum Describe postpartum patient education for women with preeclampsia Discharge instructions to include warning signs of HTN for ALL postpartum patients

94 Postpartum patients presenting to the ED with hypertension, preeclampsia or eclampsia should either be assessed by or admitted to an obstetrical service Systems should be in place to screen all women for pregnancy AND postpartum status in the ER

95 Support and communication plan for patients, families, and staff for ICU admissions and serious complications of severe hypertension

96 Timely Response Matters!Process for timely triage and evaluation of pregnant and postpartum women with hypertension, reduce time to treatment for severe range BP. Include emergency department and outpatient Rapid access to medications used for severe hypertension: medications should be stocked and immediately available. Include brief guide for administration & dosage. System plan for escalation, obtaining appropriate consultation, and maternal transport, as needed Emergency protocols – Eclampsia management, HTN treatment algorithms

97 Key Clinical Pearl Use of preeclampsia-specific checklists, team training and communication strategies, and continuous process improvement strategies will likely reduce hypertensive related morbidity. 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. Education strategies include a clear and simply written list of patient symptoms to share with patients and their families during prenatal visits and upon discharge from the hospital. Written instructions should help patients to recognize preeclampsia symptoms and seek care.

98 Readiness (every Provider and Unit)Recognition & Prevention (every patient) Response (every case of HIP) Reporting/Systems Learning (every multidisciplinary team) Unit Education on protocols, unit-based drills & simulations Establish a culture of huddles for high risk patients and post-event debriefs to identify successes and opportunities Establish a process for multi-disciplinary case reviews

99 California Pregnancy-Associated Mortality Review (CA-PAMR) Quality Improvement Review Cycle1. 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

100 Common Errors/Problems in Managing HypertensionFailure to diagnose and recognize severity of the disease Failure to initiate timely antihypertensive medication Failure to initiate appropriate Magnesium Sulfate prophylaxis Failure to initiate early transfer to higher level of care when necessary Failure to organize safe care and management plans: Moving to delivery without adequate assessments and maternal stabilization There are a number of common errors, omissions and challenges that may be used in developing the scenarios for the drills. Some of these include:….

101 Potential Clinical Scenarios for Hypertension DrillsPreeclampsia Eclampsia Hypertensive Urgency – BP ≥ 160/110(105) Stroke Hypertension in pregnancy lends itself to simulation drills because there are a number of components to recognition and prevention, that include:….

102 Goal Examples Teams will improve their response to BP > 160/110(105) hypertensive events and reduce time to treatment Teams will communicate better during hypertensive events Teams will respond in a timely fashion to signs of preeclampsia Teams will be able to efficiently evaluate a patient who presents with seizures Teams will effectively manage a patient who is actively seizing It is important to think about the reasons and goals that you have in developing the scenario. Some examples include:…

103 Huddles / Debriefs Multidisciplinary review of all severe hypertension/eclampsia, complex cases, and those admitted to ICU for systems issues, lessons learned and outcome improvement opportunities (and include patient input) Debrief (nurse / provider) all hypertensive events (BP >160/110 (105) discuss time to treatment: what went well, opportunities for improvement, team and patient communication, systems issues

104 ILPQC Maternal HTN Initiative

105 ILPQC HTN Initiative Goal & MeasuresGoal: Reduce preeclampsia maternal morbidity IL Measure Type Goal Severe Maternal Morbidity No. of women with severe maternal morbidities (e.g. Acute renal failure, ARDS, Pulmonary Edema, Puerperal CNS Disorder such as Seizure, DIC, Ventilation, Abruption) / No. pregnant & postpartum women with new onset severe range HTN Outcome 20% reduction Appropriate Medical Management in under 60 minutes No. of women treated at different time points (30,60,90, >90 min) after elevated BP is confirmed / No. of women with new onset severe range HTN Process 100% Debriefs on all new onset severe range HTN* cases Discharge education and follow-up within 7-10 days for all women with severe range HTN, 72 hours with all women with severe range HTN on medications Severe range HTN: ≥160 systolic / ≥110(105) diastolic per hospital standard *New onset severe range HTN: first episode of persistent severe range HTN (lasting >15 minutes) in a hospitalization (ER, L&D, or other inpatient setting), can be chronic HTN, gestational HTN, preeclampsia and/or postpartum diagnosis.

106 IL Maternal Hypertension: Data Form

107 Keys to Success Team Participates on Monthly Team Call4th Monday of each month 12:30-1:30 Review data, discuss QI strategies for HTN bundle implementation, education topic and Team Talks (hear from teams across IL sharing progress) Submit monthly data in RedCap Teams can track progress across time and compare to over 100 hospitals in initiative on reducing time to treatment for all patients with severe range BP Hold regular HTN Team meetings to review data, identify opportunities for improvement and drive QI work

108 Initiative Goals Early recognition of hypertension / preeclampsia triggers during pregnancy and postpartum period Reduce time to treatment of severe range blood pressure, 160/110(105) Provide patient education and appropriate discharge follow up Implementation of evidence based protocols Management of severe HTN, preeclampsia triggers, magnesium, expectant management vs delivery, postpartum management, eclampsia First and foremost, early recognition of hypertension in pregnancy is vital to managing the potential impacts. Blood pressure must be treated and guidelines have been established including treating within one hour of confirmed readings. Magnesium sulfate is not a blood pressure medication, it is for seizure control and is recommended for use in preeclampsia with severe features local protocols need to be developed and followed. Women with hypertension in pregnancy require close follow up and the full HIP toolkit provides recommendations for all women postpartum. There is a two-sided one page document in the HIP toolkit that you may find helpful in assuring that you utilize elements of the Patient Safety Bundle developed by ACOG, SMFM, AWHONN, and others for readiness, recognition, response and reporting.

109 Key Driver Diagram: Maternal Hypertension InitiativeGOAL: To reduce preeclampsia maternal morbidity in Illinois hospitals Interventions Key Drivers Implement standard order sets and/or algorithms for early warning signs, diagnostic criteria, timely triage, monitoring and treatment of severe hypertension Ensure rapid access to medications used for severe hypertension with guide for administration and dosage Implement system plan for escalation, obtaining appropriate consultation, and maternal transport Perform regular simulation drills of severe hypertension protocols with post-drill debriefs Integrate severe hypertension processes (e.g. order sets, tracking tools) into your EHR AIM: By December 2017, to reduce the rate of severe morbidities in women with preeclampsia, eclampsia, or preeclampsia superimposed on pre-existing hypertension by 20% Readiness: Implementation of standard processes for optimal care of severe maternal hypertension in pregnancy Standardize protocol for measurement and assessment of blood pressure and urine protein for all pregnant and postpartum women Standardize response to early warning signs including listening to and investigating symptoms and assessment of labs Implement facility-wide standards for patient-centered education of women and their families on signs and symptoms of severe hypertension Educate OB, ED, and anesthesiology physicians, midwives, and nurses on recognition and diagnosis of severe hypertension that includes utilizing resources such as the AIM hypertension bundle and/or unit standard protocol Recognition: Screening and early diagnosis of severe maternal hypertension in pregnancy Execute facility-wide standard protocols for appropriate medical management in under 60 minutes Create and ensure understanding of communication and escalation procedures (e.g. implementing a rapid response team through the use of TeamSTEPPS) Develop OB-specific resources and protocols to support patients, families, staff through major complications Provide patient-centered discharge education materials on preeclampsia and postpartum preeclampsia Implement patient protocols to ensure follow-up within 7-10 days for all women with severe hypertension and 72 hours for all women on medications Response: Care management for every pregnant or postpartum woman with new onset severe hypertension Reporting/Systems Learning: Foster a culture of safety and improvement for care of women with new onset severe hypertension Establish a system to perform regular debriefs after all new onset severe hypertension cases Establish a process in your hospital to perform multidisciplinary systems-level reviews on all severe hypertension cases admitted to ICU Continuously monitor, disseminate, and discuss your monthly data in ILPQC REDCap system at staff/administrative meetings Add maternal hypertension assessment and treatment protocols and education to provider and staff orientations, and annual competency assessments

110 CMQCC: 4-Step Program to Improve Preeclampsia OutcomesMake the Right Diagnosis (new criteria) Treat the BP! Deliver not too early, and not too late Patient education and early postpartum F/U

111 Need To Treat* BP ≥ 160/110(105) *BP persistent 15 minutes, activate treatment algorithm with IV therapy ASAP, < minutes

112 Sample Process Flow Diagram forManagement of Severe Range BP: Kaiser Permanente, Roseville, CA

113 AIM Baseline Survey Bundle Implementation QuestionsReadiness - For every unit in your hospital do you have (Yes/No): Standard protocols for early warning signs, diagnostic criteria, monitoring and treatment of severe preeclampsia/eclampsia (include order sets and algorithms). L&D Antepartum/Postpartum Triage/ED Unit education on protocols, unit-based drills (with post-drill debriefs). Process for timely identification, triage, and evaluation of pregnant and postpartum women with hypertension including ED and outpatient areas. Rapid access to IV medications used for severe hypertension/eclampsia: Medications should be stocked and immediately available on L&D and in other areas where patients may be treated. Include brief guide for administration and dosage. System plan for escalation, obtaining appropriate consultation and maternal transport, as needed for severe maternal hypertension, preeclampsia, and eclampsia.

114 AIM Baseline Survey Bundle Implementation QuestionsRecognition - For every OB/postpartum patient in your hospital do you have (Yes/No): 6. Standard protocol for the measurement and assessment of BP and urine protein for all pregnant and postpartum women. 7. Standard response to maternal early warning signs including listening to and appropriately investigating patient symptoms and assessment of labs (i.e. CBC with platelets, AST and ALT) 8. Facility-wide standards for educating prenatal and postpartum women on signs and symptoms of preeclampsia and severe hypertension.

115 AIM Baseline Survey Bundle Implementation QuestionsResponse - For every case of severe hypertension/preeclampsia in your hospital do you have (Yes/No): 9. Facility-wide standard protocols with checklists and escalation policies for management and treatment of: Severe hypertension; Eclampsia, seizure prophylaxis, and magnesium over-dosage; and Postpartum, emergency department and outpatient presentations of severe hypertension/preeclampsia. 10. Minimum requirements for protocol: Notification of physician or primary care provider if systolic BP =/>160 or diastolic BP =/>110 for two measurements within 15 minutes; After the second elevated reading, treatment should be initiated ASAP (preferably within 60 minutes of verification); Includes onset and duration of magnesium sulfate therapy when indicated; Includes escalation measures for those unresponsive to standard treatment; Describes manner and verification of timely follow-up for blood pressure check and evaluation within 7 to 14 days postpartum; Describes postpartum patient education for women with hypertension / preeclampsia describing postpartum preeclampsia. 11. Support plan for patients, families, and staff for ICU admissions and serious complications of severe hypertension.

116 AIM Baseline Survey Bundle Implementation QuestionsReporting - In every unit of your hospital, do you (Yes/No): 11. Establish a culture of huddles for high-risk patients and post-event debriefs to identify successes and opportunities for improvement. L&D Antepartum/Postpartum Triage/ED 12. Multidisciplinary review of all severe hypertension/eclampsia cases admitted to ICU for systems issues. 13. Monitor quality outcomes and process metrics involving severe hypertension in pregnancy.

117 HTN Initiative Monthly Team Calls: ScheduleCall Date Topic June 27 12:30 – 2:30 pm Readiness and Reporting - Bundle / Toolkit Overview AND Drills, Simulation, and Debriefs July 25 12:30 – 1:30 pm Recognition - Accurate BP Measurement & Diagnosis August 22 Response - BP Medication and Treatment Algorithms September 26 Response - Timing of Delivery October 24 Response - Patient Education/Engagement and Postpartum Follow-up

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119 Additional Resources Preeclampsia Foundation tools and materials California Maternal Quality Care Collaborative Patient safety bundles and AIM program information ACOG DII (New York) Safe Motherhood Initiative https://www.acog.org/About-ACOG/ACOG-Districts/District-II/Safe-Motherhood-Initiative Illinois Perinatal Quality Collaborative (ILPQC) There are other resources available for HIP that include:….

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