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To assess the effect of an anti-hypertensive pathway order set in improving treatment of hypertensive emergency in pregnant and postpartum women
Study Design
A multi-disciplinary task force created a hypertensive pathway order set and provided staff training. Pregnant and postpartum women documented to have 2 or more consecutive severe range blood pressures (srBP) in the year prior (2017) and the year after (2019) implementation of the pathway were included. Use of short-acting antihypertensive (aHTN) (intravenous labetalol, intravenous hydralazine, or oral nifedipine) were considered appropriate treatment. Outcomes measured were whether aHTN was given at all, whether it was given for all instances of srBP, and time to aHTN administration. Rates of aHTN provision were compared before and after implementation of the standard order set.
Results
A total of 566 women with srBP were included, with 304 women in 2017 and 262 in 2019. There were no differences in age, parity, gestational age, race, or ethnicity between cohorts. There were more preeclampsia diagnoses in 2019 than 2017 (79% vs. 59%, p<0.01) (Table 1). The rates of aHTN administration improved significantly with use of the pathway—67% in the pre-intervention cohort received an aHTN at least once vs. 80% post-intervention (p<0.01) (Table 2). Significant improvement was also evident for receipt of aHTN for all instances of srBP (29% pre-intervention vs. 47% post-intervention, p<0.01). There was a significant decrease in time to administration of aHTN (39.7 minutes [SD=33.8] pre-intervention vs. 14.9 minutes [SD=20.7] post-intervention, p<0.01).
Conclusion
There was an improvement in rates of and time to aHTN administration to pregnant and postpartum women after implementation of the hypertensive pathway, though rates did not approach 100%. These results are likely mediated by improved workflow, allowing greater nurse autonomy after a physician has initiated the pathway. There was also an increased rate of preeclampsia diagnosis in 2019, perhaps reflecting improved recognition. Future work will focus on cognitive aids for srBP recognition.
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