Abstract：
BACKGROUND: An institutional standardized, nurse-initiated protocol was implemented to improve the recognition of and response to perinatal hypertensive emergency.
OBJECTIVE: The primary aim was to evaluate if the rate of guideline-based treatment of perinatal hypertensive emergency improved with implementation of the protocol.
METHODS: This quality improvement initiative was developed by a multidisciplinary team and consisted of clinician and nursing education and the implementation of a standardized, nurse-initiated severe hypertension protocol. The project took place in three phases: pre-implementation (July 2020-October 2020), implementation (November 2020-June 2021), and sustainment (July 2021-May 2022). The primary aim was to increase guideline-based treatment of hypertensive emergency among pregnant and postpartum persons. Guideline-based treatment was defined as repeat blood pressure within 30 minutes of severe hypertension to diagnose hypertensive emergency, antihypertensive medication administration within 30 minutes of diagnosis, and appropriately timed repeat blood pressure following treatment. Process measures included time to confirm the diagnosis, initiate the protocol, antihypertensive medication administration, repeat blood pressure after antihypertensive medication administration, and administration of a secondary dose as appropriate. Balancing measures included maternal intensive care unit admission, clinically significant maternal hypotension, fetal demise, neonatal birthweight, and Apgar <7 at 5 minutes. Data were evaluated using between-subjects statistics and a run chart was developed to assess relationship between the protocol and changes in guideline-based treatment over time.
RESULTS: Overall, 503 hypertensive emergency encounters were identified during the project period (98 [20%] pre-implementation, 172 [34%] implementation, 233 [46%] sustainment). There were higher rates of persons with chronic hypertension and who self-identified as non-Hispanic Black race in the sustainment phase compared to the other phases. Guideline-based treatment increased from 18.4% pre-implementation to 75.1% in sustainment (p<0.001). Each component of guideline-based treatment also improved significantly from pre-implementation to sustainment (p<0.001). No episodes of clinically significant maternal hypotension occurred in any phase. There were four maternal intensive care unit admissions and three fetal demises during the initiative; none were related to hypertensive emergency.
CONCLUSIONS: The nurse-initiated protocol for treatment of hypertensive emergency significantly increased guideline-based treatment of perinatal hypertensive emergency, reduced time to diagnose and treat hypertensive emergency, and increased the number of patients receiving treatment when indicated. This protocol was pragmatic, utilizing resources already available on obstetric units. Use of similar protocols may be considered at institutions providing obstetric care to improve recognition of and response to hypertensive emergency which may decrease maternal and neonatal morbidity and mortality related to hypertensive emergency.
OBJECTIVE: The primary aim was to evaluate if the rate of guideline-based treatment of perinatal hypertensive emergency improved with implementation of the protocol.
METHODS: This quality improvement initiative was developed by a multidisciplinary team and consisted of clinician and nursing education and the implementation of a standardized, nurse-initiated severe hypertension protocol. The project took place in three phases: pre-implementation (July 2020-October 2020), implementation (November 2020-June 2021), and sustainment (July 2021-May 2022). The primary aim was to increase guideline-based treatment of hypertensive emergency among pregnant and postpartum persons. Guideline-based treatment was defined as repeat blood pressure within 30 minutes of severe hypertension to diagnose hypertensive emergency, antihypertensive medication administration within 30 minutes of diagnosis, and appropriately timed repeat blood pressure following treatment. Process measures included time to confirm the diagnosis, initiate the protocol, antihypertensive medication administration, repeat blood pressure after antihypertensive medication administration, and administration of a secondary dose as appropriate. Balancing measures included maternal intensive care unit admission, clinically significant maternal hypotension, fetal demise, neonatal birthweight, and Apgar <7 at 5 minutes. Data were evaluated using between-subjects statistics and a run chart was developed to assess relationship between the protocol and changes in guideline-based treatment over time.
RESULTS: Overall, 503 hypertensive emergency encounters were identified during the project period (98 [20%] pre-implementation, 172 [34%] implementation, 233 [46%] sustainment). There were higher rates of persons with chronic hypertension and who self-identified as non-Hispanic Black race in the sustainment phase compared to the other phases. Guideline-based treatment increased from 18.4% pre-implementation to 75.1% in sustainment (p<0.001). Each component of guideline-based treatment also improved significantly from pre-implementation to sustainment (p<0.001). No episodes of clinically significant maternal hypotension occurred in any phase. There were four maternal intensive care unit admissions and three fetal demises during the initiative; none were related to hypertensive emergency.
CONCLUSIONS: The nurse-initiated protocol for treatment of hypertensive emergency significantly increased guideline-based treatment of perinatal hypertensive emergency, reduced time to diagnose and treat hypertensive emergency, and increased the number of patients receiving treatment when indicated. This protocol was pragmatic, utilizing resources already available on obstetric units. Use of similar protocols may be considered at institutions providing obstetric care to improve recognition of and response to hypertensive emergency which may decrease maternal and neonatal morbidity and mortality related to hypertensive emergency.
摘要：
背景：机构标准化，实施了由护士发起的方案,以提高对围产期高血压急症的认识和反应.
目的：主要目的是评估基于指南的围产期高血压急症治疗率是否随着方案的实施而提高。
方法：这项质量改进计划是由一个多学科团队开发的，包括临床医生和护理教育以及标准化，护士发起的重度高血压方案。该项目分三个阶段进行：预实施（2020年7月-2020年10月），实施（2020年11月-2021年6月），和维持（2021年7月至2022年5月）。主要目的是在孕妇和产后人群中增加基于指南的高血压急症治疗。以指南为基础的治疗被定义为在重度高血压的30分钟内重复血压以诊断高血压急症，在诊断后30分钟内服用抗高血压药物，治疗后适当定时重复血压。过程措施包括确认诊断的时间，启动协议，抗高血压药物管理，服用抗高血压药物后重复血压，并酌情给予第二剂量。平衡措施包括孕产妇重症监护病房入院，具有临床意义的产妇低血压，胎儿死亡,新生儿出生体重,和Apgar<7在5分钟。使用受试者之间的统计数据来评估数据，并开发了运行图表来评估方案与基于指南的治疗随时间的变化之间的关系。
结果：总体而言，在项目期间确认了503次高血压急症(98[20%]预实施,172[34%]实施，233[46%]维持）。与其他阶段相比，在维持阶段，患有慢性高血压和自我鉴定为非西班牙裔黑人种族的人的比率更高。在维持方面，基于指南的治疗从实施前的18.4%增加到75.1%(p<0.001)。从实施前到维持，基于指南的治疗的每个组成部分也有了显着改善（p<0.001）。在任何阶段均未发生临床上显着的产妇低血压发作。倡议期间有4例产妇重症监护病房入院和3例胎儿死亡；没有与高血压紧急情况有关。
结论：护士发起的高血压急症治疗方案显著增加了围产期高血压急症的指南治疗，缩短诊断和治疗高血压急症的时间，并增加了接受治疗的患者数量。这个协议是务实的，利用产科单位已经可用的资源。在提供产科护理的机构中可以考虑使用类似的方案，以提高对高血压紧急情况的认识和反应，这可能会降低与高血压紧急情况相关的孕产妇和新生儿发病率和死亡率。
目的：主要目的是评估基于指南的围产期高血压急症治疗率是否随着方案的实施而提高。
方法：这项质量改进计划是由一个多学科团队开发的，包括临床医生和护理教育以及标准化，护士发起的重度高血压方案。该项目分三个阶段进行：预实施（2020年7月-2020年10月），实施（2020年11月-2021年6月），和维持（2021年7月至2022年5月）。主要目的是在孕妇和产后人群中增加基于指南的高血压急症治疗。以指南为基础的治疗被定义为在重度高血压的30分钟内重复血压以诊断高血压急症，在诊断后30分钟内服用抗高血压药物，治疗后适当定时重复血压。过程措施包括确认诊断的时间，启动协议，抗高血压药物管理，服用抗高血压药物后重复血压，并酌情给予第二剂量。平衡措施包括孕产妇重症监护病房入院，具有临床意义的产妇低血压，胎儿死亡,新生儿出生体重,和Apgar<7在5分钟。使用受试者之间的统计数据来评估数据，并开发了运行图表来评估方案与基于指南的治疗随时间的变化之间的关系。
结果：总体而言，在项目期间确认了503次高血压急症(98[20%]预实施,172[34%]实施，233[46%]维持）。与其他阶段相比，在维持阶段，患有慢性高血压和自我鉴定为非西班牙裔黑人种族的人的比率更高。在维持方面，基于指南的治疗从实施前的18.4%增加到75.1%(p<0.001)。从实施前到维持，基于指南的治疗的每个组成部分也有了显着改善（p<0.001）。在任何阶段均未发生临床上显着的产妇低血压发作。倡议期间有4例产妇重症监护病房入院和3例胎儿死亡；没有与高血压紧急情况有关。
结论：护士发起的高血压急症治疗方案显著增加了围产期高血压急症的指南治疗，缩短诊断和治疗高血压急症的时间，并增加了接受治疗的患者数量。这个协议是务实的，利用产科单位已经可用的资源。在提供产科护理的机构中可以考虑使用类似的方案，以提高对高血压紧急情况的认识和反应，这可能会降低与高血压紧急情况相关的孕产妇和新生儿发病率和死亡率。
