Improving Outcomes of Preeclampsia in California: From Review of Maternal Death to Quality Care Collaboratives

Sunday, June 15, 2014

Title: Improving Outcomes of Preeclampsia in California: From Review of Maternal Death to Quality Care Collaboratives

Christine H. Morton, PhD , California Maternal Quality Care Collaborative, Stanford University, Palo Alto, CA
Nancy Peterson, RNC, PNNP, MSN, IBCLC , California Maternal Quality Care Collaborative, Stanford University, Palo Alto, CA

Discipline: Childbearing (CB), Professional Issues (PI), Women’s Health (WH)

Learning Objectives:
  1. Identify blood pressure values requiring a higher level of nursing care and supervision
  2. Critically evaluate women’s risk factors and co-morbid conditions in the presence of elevated blood pressure values.
  3. Describe healthcare provider and facility factors that contribute to preeclampsia deaths.
Submission Description:
Objective:  To describe characteristics of California women who died from preeclampsia/eclampsia in 2002-2004, identify contributing factors and quality improvement opportunities, and report on process and outcome measures from a multi-hospital, statewide learning collaborative which implemented a Maternity Care Improvement Preeclampsia Toolkit.

Design: In 2004, the California Maternal, Child and Adolescent Health Division developed an enhanced surveillance method to identify maternal deaths from administrative data, whose abstracted medical records were reviewed by an expert Committee to determine causes of death and opportunities for prevention.  

Setting: Data were collected as part of the California Pregnancy-Associated Mortality Review (CA-PAMR) and from CA-PAMR committee determination, after case review.  Data collection included classification of pregnancy-relatedness, contributing factors and quality improvement opportunities.  Learning Collaborative participants submitted process and outcomes measures related to the implementation of the Preeclampsia Toolkit.

Sample: 145 cases of pregnancy-related deaths from preeclampsia/eclampsia in California, 2002-2004; 26 hospitals in a statewide learning collaborative.

Methods: Mixed methods analysis was conducted of the CA-PAMR data; Learning Collaborative data were analyzed using frequency and trend charts.

Results:   After case review, 145 maternal deaths from 2002-2004 were determined to be pregnancy-related. Preeclampsia was the second leading cause of death accounting for 17% of all pregnancy-related deaths in 2002-2004.  The women who died from preeclampsia in California from 2002-2004 were more likely to be Hispanic, multiparous, and have normal BMI compared to women who died of other pregnancy-related causes.  Nearly all (n=24/25) of these deaths were determined to have some degree of preventability, with half having a good-to-strong chance.  Analysis of the opportunities to improve quality and reduce preventable maternal deaths revealed themes related to the need for recognition and response to clinical triggers (i.e., warning signs) in clinical status and care coordination.

Learning collaborative participants reported increased levels of awareness and education regarding the importance of treating severe hypertension in pregnant women as a result of debriefing activity.  Sites improved methods for medical chart documentation and coding, and overall data quality improvements as they apply to women with hypertensive disorders including preeclampsia.

Conclusion/Implications for nursing practice:   Implementation of the Preeclampsia Toolkit in the multi-hospital, statewide Learning Collaborative is intended to reduce rates of severe maternal morbidity and prolonged postpartum length of stay. Learning Collaborative participants, who adopted the Toolkit, showed measurable improvement in their sites' ability to respond to this leading cause of pregnancy-related morbidity and mortality. 

Keywords:  Preeclampsia/Eclampsia; Pregnancy-related mortality; severe hypertension; quality improvement

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