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Problem statement
At the hospital in this project, patients with hypertensive disorders of pregnancy are asked to return to the clinic for a blood pressure check within a week of discharge, but a chart review found that fewer than half attend. Transportation, childcare and recovery from birth make visits hard, so dangerous rises in blood pressure after discharge may go undetected. The hospital and its figures are illustrative.
Background
Hypertensive disorders of pregnancy are among the leading causes of maternal and perinatal mortality worldwide, and preeclampsia complicates an estimated 2% to 8% of pregnancies globally (American College of Obstetricians and Gynecologists [ACOG], 2020). Blood pressure can rise in the days after birth, so monitoring after discharge matters. ACOG's practice bulletin defines severe-range blood pressure as a systolic of 160 mm Hg or more or a diastolic of 110 mm Hg or more, which needs urgent treatment.
Evidence for the intervention
In a randomized trial of 206 postpartum patients with pregnancy-related hypertension, patients received either 2 weeks of text-based monitoring using a home blood pressure cuff and an automated messaging platform, or the usual office blood pressure check 4 to 6 days after discharge. At least one blood pressure was recorded in the first 10 days in 92.2% of the texting group versus 43.7% of the office group, and 84% of the texting group had readings on both days 3 to 4 and days 7 to 10, meeting ACOG's recommendations (Hirshberg et al., 2018).
Project aim
Within 6 months, at least 80% of patients discharged with a hypertensive disorder of pregnancy will have blood pressure readings recorded on postpartum days 3 to 4 and 7 to 10, and 100% of severe-range readings will receive a clinical response within the protocol's time limit.
Framework
The project uses the Model for Improvement with Plan-Do-Study-Act cycles and RE-AIM to plan for reach and maintenance.
Project design
| Element | Plan |
|---|---|
| Population | All postpartum patients with gestational hypertension, preeclampsia or chronic hypertension at discharge |
| Intervention | A validated home blood pressure cuff before discharge; teaching with teach-back; twice-daily text prompts to send readings for 2 weeks |
| Response protocol | Automated advice for normal readings; nurse callback within 1 hour for elevated readings; instructions to go to the emergency department and immediate provider notification for severe-range readings or symptoms such as severe headache, vision changes or shortness of breath |
| Staffing | A nurse covers the monitoring dashboard during clinic hours, with an on-call pathway after hours |
| Equity | Cuffs provided at no cost; messages in the patient's preferred language; data reviewed by race, ethnicity and insurance |
Measures
- Process: percentage of eligible patients enrolled; percentage sending readings on days 3 to 4 and 7 to 10.
- Outcome: time from a severe-range reading to treatment; postpartum readmissions and emergency visits for hypertension.
- Balancing: nurse time spent on monitoring; patient-reported burden.
Stakeholders and approvals
The project team includes obstetric nurses, obstetricians, midwives, the outpatient clinic and the informatics team. The plan will be reviewed by the hospital's quality improvement committee, and the institutional review board will be asked to determine whether it qualifies as quality improvement.
References
American College of Obstetricians and Gynecologists. (2020). Gestational hypertension and preeclampsia: ACOG practice bulletin, number 222. Obstetrics & Gynecology, 135(6), e237–e260. https://doi.org/10.1097/AOG.0000000000003891
Hirshberg, A., Downes, K., & Srinivas, S. (2018). Comparing standard office-based follow-up with text-based remote monitoring in the management of postpartum hypertension: A randomised clinical trial. BMJ Quality & Safety, 27(11), 871–877. https://doi.org/10.1136/bmjqs-2018-007837
