(1171) Maternal Hypertension Care Bundle Implementation at an Academic Tertiary Hospital: System Redesign using Improvement Science

Objective: Uncontrolled hypertension in pregnancy is a major cause of maternal morbidity and mortality. Application of best-practice maternal hypertension care bundle reduces severe maternal morbidity. Our objective was to implement an in-patient, maternal hypertension bundle (HTN-bundle) with reliable adherence of >80% in an academic tertiary care hospital.

Study Design: University of Cincinnati Medical Center is a level IV maternal care academic center, safety net hospital. We participated in the AIM Hypertension Quality Improvement Project (AIM-QIP) by the Ohio Colleges of Medicine Government Resource Center.

The HTN-bundle consisted of 1) treatment of systolic blood pressure (BP) or diastolic BP ≥ 160/110 in < 60 min, 2) appropriate medication use for acute HTN treatment, 3) patient education, 4) timely discharge follow-up, 5) blood pressure cuff provision. We aimed to improve the adherence to bundle components from 62% (baseline) to >80% within 6-months.

Staff education was led by the medical director and facilitated by AIM-QIP. We performed detailed process maps, Pareto analyses, empathy mapping, and Go-see activities to identify improvement opportunities. Interventions for redesign were testing using iterative Plan-Do-Study-Act (PDSA) cycles (Fig 1). Bundle adherence was tracked by chart reviews and plotted on run-chart.

Results: The baseline HTN-bundle adherence was 62%. We performed 33 PDSA cycles, testing 16 interventions. By 6-months, HTN-Bundle adherence reached 84% with a sustainable system shift on the run-chart (Fig 2). The highest increases were noted in provision of BP cuffs and 3-day follow-up BP check appointments. The HTN-bundle delivery now relies on different team members performing inter-dependent task, making it a system property rather than an individual’s responsibility.

Conclusion: Using improvement science methods, adherence to HTN-bundle can be made a part of reliable, standard-of-care for all affected patients. Key success factors were setting a clear aim, team engagement, QI expertise, data-guided change efforts, and availability of resources.