A Systems-Based Approach to Improving Emergency Department Management of Severe Maternal Hypertension

Severe maternal hypertension is a time-sensitive obstetric emergency. ACOG recommends initiation of antihypertensive therapy within 30-60 minutes of persistent severe-range BP during pregnancy or the postpartum period to reduce the risk of stroke, seizure, and end-organ injury. Our objective was to evaluate the effectiveness of stepwise system-level interventions on guideline concordant treatment.

A retrospective, quasi-experimental study of pregnant (≥ 20 weeks) and postpartum (≤ 6 weeks) ED patients with severe hypertension defined as SBP ≥160 mmHg and/or DBP ≥110 mmHg on two measurements 15-minutes apart. Patients were grouped into four additive implementation periods: pre-popup, post-popup/pre-pathway (Nov 25th, 2020), post-pathway/pre-overhead alert (Sep 8th, 2021 for version 1 and Sept 2023 for version 2), and post-overhead alert (Feb 5th, 2024). Primary outcomes were time to antihypertensive administration and treatment within 60 mins. Multivariable regression models compared each intervention period with the pre-popup baseline.

Sequential implementation of system-level interventions was associated with progressive improvement in treatment timeliness. In the pre-popup phase (N = 92), median time to treatment was 46 mins (IQR 28–71), with 64% of patients treated within 60 mins. Following popup implementation (N=43), median time decreased to 35 mins (IQR 20–56), and timely treatment increased to 84%. During the post-pathway phase, median time was 47 mins (IQR 28–57), with 78% treated within 60 minutes. The overhead alert produced the greatest improvement, reducing median time to 20 mins (IQR 14–33) and increasing timely treatment to 92% with less variability. In adjusted analyses, compared with the pre-popup period, the odds of treatment within 60 minutes increased after popup implementation (OR 1.86, 95% CI 1.00–3.48; p=0.051), were not significantly different during the post-pathway phase (OR 1.43, 95% CI 0.90–2.26), and were significantly higher following implementation of the overhead alert (OR 3.24, 95% CI 1.60–6.88; p=0.002).

A multi-layered, systems-based intervention integrating electronic alerts, standardized workflows, and real-time escalation was associated with substantial improvements in timely treatment of severe maternal hypertension in the ED, supporting its use as a scalable ED-based maternal safety strategy.