Is the implementation of a standardized postpartum hypertension management protocol associated with a reduction in emergency department visits and readmissions?
Implementation of practice guidelines for patients with postpartum hypertension (chronic and hypertensive disorders of pregnancy) to improve BP control from delivery until 6 weeks postpartum was associated with a significant decrease in ED visits and readmissions related to hypertension. Keys to the intervention were remote BP monitoring and medication titration accordingly.
Inpatient (any location) with outpatient follow-up
These investigators conducted a prospective cohort study (n = 390) of the implementation of a standardized institution-specific postpartum blood pressure (BP) management protocol to reduce emergency department (ED) visits and readmissions. They used a historical control group (n = 390) from the same institution to compare results before and after the intervention. Inclusion criteria were age at least 18 years and a diagnosis of chronic hypertension or hypertensive disorder of pregnancy. The authors excluded patients with delivery before 24 weeks' gestation or stillbirth. The guidelines included inpatient and outpatient phases. Inpatient recommendation was initiation or uptitration of medication for BP greater than 150/100 mm Hg (or 2 readings greater than 140/90 in a 24-hour period) with the goal of BP less than140/90 for at least 12 hours prior to discharge. The outpatient phase consisted of home BP monitoring twice daily, recorded in the electronic health record (EHR). The patient was prompted by the EHR to reach out to a physician for any abnormal reading, and the EHR simultaneously sent notification to a physician on the study team. BP monitoring continued for 6 weeks postpartum. The primary outcome was a composite of at least one ED visit or readmission for preeclampsia requiring the administration of magnesium sulfate for seizure prophylaxis; persistent symptoms such as refractory headache, visual disturbances, severe right upper quadrant pain, chest pain, or shortness of breath; or uncontrolled severe-range BP readings despite outpatient medication titration. This primary outcome occurred in 11.0% before implementation and 2.8% of patients postimplementation (adjusted odds ratio 0.24; 95% CI 0.12 - 0.49; P < .001; number needed to treat = 12; 8 - 21). Results were similar for both ED visits and readmissions when analyzed separately. Of note is that this treatment protocol is relatively aggressive and the there was a 9% incidence of hypotension. Compliance with remote BP monitoring was higher among patients with commercial insurance (80%) than those with other types of insurance (60%).
Linda Speer, MD
Professor and Chair, Department of Family Medicine
University of Toledo