- Iriye B.K.
- Gregory K.D.
- Saade G.R.
- Grobman W.A.
- Brown H.L.
|Brief title||The timely initiation of the treatment of severe hypertension (severe HTN) in obstetrical patients|
|Narrative description||The percentage of obstetrical patients with one or more persistent severe HTN episode(s) in which treatment with a standard antihypertensive agent is initiated within 60 minutes of the onset of the first episode or in which the first episode resolves within 60 minutes without such treatment.|
|Definitions||Obstetrical patient: A person who is pregnant at any gestational age or within 42 d (6 wk) postpartum|
Severe hypertension (severe HTN): A systolic BP of 160 mm Hg or more, or a diastolic BP of 110 or more, or both.
Severe HTN episode: A set of consecutive BP measurements from a given patient in which both of the following criteria are met:
Persistent severe HTN episode: A severe HTN episode in which either:
|Measure denominator||The number of obstetrical patients with 1 or more persistent severe HTN episodes at the facility|
|Measure numerator||The number of episodes in the denominator in which EITHER:|
|Measure calculation||Numerator divided by denominator, expressed as a percentage|
|Type of measure||Process|
|Improvement reflected by||Increasing percentage|
|Suggested measurement period||A calendar week for facilities with high obstetrical volume, otherwise a calendar month|
|Possible levels of evaluation||Hospital or birthing center|
|Exclusions from denominator||None|
|Exclusions from numerator||None|
|Data source for denominator||Electronic records of blood pressure measurements|
Additional cases for the denominator may be captured by searching for the ICD-10 discharge diagnosis codes:
|Data source for numerator||Electronic pharmacy records|
Critique of the Measure
|Critique||Question or problem||Counterpoint|
|It is a process measure.||Why not use an outcome measure such as BP restored to nonsevere HTN range within 60 minutes?||Even with appropriate treatment, some patients are refractory to treatment, so we cannot reasonably expect that 100% of the episodes will be restored to nonsevere HTN within a given time. However, it is possible to have 100% compliance with the process.|
|An episode can be considered persistent even if there is only 1 severe HTN observation in the episode.||If the BP is not rechecked within 15 minutes, the episode is defined as persistent.||The burden of proof is on providers to document that the BP has declined to the nonsevere range. Failure to recheck the BP promptly is a quality gap that should be tracked and acted on.|
|The metric should be based on the time after confirmed persistent severe HTN, not the time after the first observation of severe HTN.||This metric was proposed by the Cooperative Workshop.||A long delay in repeating the BP measurement would result in delayed treatment that would not be captured if the metric was based on the time after repeat BP.|
|The metric should be based on treatment within 30 min of episode onset, not 60 min.||ACOG recommends antihypertensive treatment “as soon as reasonably possible” and cites literature suggesting “within 30–60 minutes.”||The facilities are encouraged to adopt a stricter 30-minute standard for the numerator once they have achieved a reasonable rate using the 60-minute standard.|
|The metric should include all episodes of severe HTN, not just the first episode for each patient.||Tracking only the first episodes may give an incomplete picture. Personnel may become complacent about the timely treatment of repeated episodes.||Basing the metric on first episodes was a compromise intended to decrease the administrative burden of ascertaining the data. Facilities that could automate ascertainment are encouraged to track all episodes. The assumption that timely treatment of a first episode correlates with timely treatment of all episodes should be tested.|
|Episode onset time should be based on the first severe HTN observation wherever it occurs, even if it occurs on nonobstetrical units.||Exclusion of values obtained outside the obstetrical units will lead to missed opportunities to improve a timely response to severe HTN in the emergency department and the ICU.||Exclusion of outlying units was a compromise made because of difficulty in identifying obstetrical patients on those units and issues of interoperability of vital signs databases among different hospital units.|
|The list of included antihypertensive agents is too limited.||Clinicians may treat with different antihypertensive agents than those listed and achieve good BP control.||For their own tracking purposes, facilities can add agents to the list consistent with institutional protocols. However, we discourage individual providers from choosing agents based on idiosyncratic preferences, because such variation can be a source of miscommunication and other medical errors. Thus, each facility should have a limited number of agents to consider in tracking the metric.|
|Magnesium sulfate seizure prophylaxis is not included.||ACOG recommends magnesium sulfate for patients with severe HTN.||Although magnesium sulfate is recommended, it is not considered an antihypertensive agent and does not effectively restore the BP to nonsevere HTN levels.|
|Possible unintended adverse effects could occur.||Aggressive treatment of severe HTN may result in maternal hypotension, fetal heart rate decelerations, and an increased cesarean delivery rate.||Hypotension after appropriate antihypertensive treatment is uncommon and rarely leads to fetal compromise requiring immediate delivery. Balancing metrics such as rates of maternal hypotension and cesarean delivery for fetal indications can be tracked.|
|Administrative efforts to capture data and calculate a rate are burdensome.||Quality metrics that require manual chart review and manual calculation are viewed with disfavor.||The metric is designed to work with a database that includes all consecutive blood pressures on all obstetrical patients during a measurement period. A computer programmer can write a program to calculate the metric automatically.|
|The definition of persistent severe HTN episode is complex.||A computer programmer must set up all the possible definitions and variations regarding what is and what is not persistent severe HTN. Not all facilities have the resources to accomplish this programming.||The programming need only be done once; then it can apply to all subsequent measurement periods with no additional work.|
|The BP data must be merged with the pharmacy data.||The BP measurements are in 1 data stream in the electronic record and the medication records are in another.||Merging the 2 data streams is a fairly straightforward database management function.|
|Can the metric be stratified by race, ethnicity, and other demographic characteristics?||There is a high rate of maternal mortality among Black and African-American people. The existing evidence suggests that the timely treatment of severe HTN is less likely in White people.||The metric is readily stratified by race, ethnicity, and other characteristics as long as these data are captured in the EHR and extracted for analysis.|
|The metric should be tracked at the level of individual providers or provider groups rather than the entire facility.||The identification of outlier individuals can be a step in driving performance improvement.||The number of cases attributable to individual providers is likely too low for meaningful comparisons. Facilities often find that system-wide improvements are more effective than provider-level change.|
|Payors cannot track this metric based on claims data.||The claims data are based on the date of service and do not contain the detailed time-of-day information needed to ascertain the numerator and denominator.||The metric is not intended to be used by payors as a part of pay-for-performance or value-based reimbursement programs. It is intended to help facilities evaluate and improve their care.|
|Can knowledge of this metric be used to motivate and track quality improvement projects?||There is a paucity of published experience to demonstrate that the rate of timely treatment can be improved.||Unpublished experience from AIM and some state quality collaboratives suggests that improvement is achievable.|
- Iriye B.K.
- Gregory K.D.
- Saade G.R.
- Grobman W.A.
- Brown H.L.
Potential Uses of the Metric
Provision of care, treatment, and services standards for maternal safety.
Measure evaluation criteria. 2012.
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- Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure.Obstet Gynecol. 2005; 105: 246-254
- Gestational hypertension and preeclampsia: ACOG Practice Bulletin, Number 222.Obstet Gynecol. 2020; 135: e237-e260
- ACOG Practice Bulletin No. 203: chronic hypertension in pregnancy.Obstet Gynecol. 2019; 133: e26-e50
- Identification of factors associated with delayed treatment of obstetric hypertensive emergencies.Am J Obstet Gynecol. 2020; 223: 250.e1-250.e11
- Factors associated with appropriate treatment of acute-onset severe obstetrical hypertension.Am J Obstet Gynecol. 2021; 225: 329.e1-329.e10
- Early standardized treatment of critical blood pressure elevations is associated with a reduction in eclampsia and severe maternal morbidity.Am J Obstet Gynecol. 2017; 216: 415.e1-415.e5
- Reducing time to treatment for severe maternal hypertension through statewide quality improvement.Am J Obstet Gynecol. 2018; : 218
- Impact statements.(Available at:)https://safehealthcareforeverywoman.org/wp-content/uploads/AIM-Impact-Statements-June-2021.pdfDate: 2021Date accessed: September 28, 2021
- Pulse pressure as a predictor of response to treatment for severe hypertension in pregnancy.Am J Obstet Gynecol MFM. 2021; 3: 100455
- Quality measures in high-risk pregnancies: executive summary of a cooperative workshop of the Society for Maternal-Fetal Medicine, National Institute of Child Health and Human Development, and the American College of Obstetricians and Gynecologists.Am J Obstet Gynecol. 2017; 217: B2-B25
- Risks of parenteral antihypertensive therapy for the treatment of severe maternal hypertension are low.Hypertens Pregnancy. 2016; 35: 123-128
- Society for Maternal-Fetal Medicine (SMFM) Special Report: current approaches to measuring quality of care in obstetrics.Am J Obstet Gynecol. 2016; 215: B8-B16
- SMFM scorecard 2020–2021.(Available at:)
- Provision of care, treatment, and services standards for maternal safety.(Available at:)https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_24_maternal_safety_hap_9_6_19_final1.pdfDate: 2019Date accessed: September 28, 2021
- Measure evaluation criteria. 2012.(Available at:)https://www.qualityforum.org/Measuring_Performance/Submitting_Standards/Measure_Evaluation_Criteria.aspx#usabilityDate accessed: September 28, 2021
The Alliance for Innovation on Maternal Health (AIM) is a cooperative agreement between the American College of Obstetricians and Gynecologists (ACOG) and the Maternal Child Health Bureau of the United States Health Resources and Services Administration. AIM seeks to provide standardized approaches to address the drivers of maternal mortality and severe maternal morbidity in the United States. E.M. is a Consulting Quality Improvement Director for AIM. I.T. and C.A. are ACOG staff for the AIM program.
All authors and Committee members have filed a disclosure of interests delineating personal, professional, business, or other relevant financial or nonfinancial interests in relation to this publication. Any substantial conflicts of interest have been addressed through a process approved by the Society for Maternal-Fetal Medicine (SMFM) Board of Directors. SMFM has neither solicited nor accepted any commercial involvement in the specific content development of this publication.
This document has undergone an internal peer review through a multilevel committee process within SMFM. This review involves critique and feedback from the SMFM Patient Safety and Quality and Document Review Committees and final approval by the SMFM Executive Committee. SMFM accepts sole responsibility for document content. SMFM publications do not undergo editorial and peer review by the American Journal of Obstetrics & Gynecology. The SMFM Patient Safety and Quality Committee reviews publications every 36 to 48 months and issues updates as needed. Further details regarding SMFM Publications can be found at www.smfm.org/publications.
SMFM recognizes that obstetrical patients have diverse gender identities and is striving to use gender-inclusive language in all of its publications. SMFM will be using terms such as “pregnant person/persons” or “pregnant individual/individuals” instead of “pregnant woman/women” and will use the singular pronoun “they.” When describing the study populations used in research, SMFM will use the gender terminology reported by the study investigators.
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