Comprehensive Educational
Model for PIH Training
Maricopa Medical Center, Phoenix, AZ
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Objectives
• Provide an educational model for PIH training,
incorporating effective simulation for participants
to integrate into your organizational practice
• Share CMQCC initiatives & toolkit
• Identify predictors of PIH through nursing
assessment and incorporate appropriate
interventions
• Recognize the value of simulation and debriefing
components to overall improved patient
outcomes
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U.S. Maternal Mortality
• CDC Review of 14 years of coded data 1979-1992
• 4024 maternal deaths
• 790 (19.6%) from preeclampsia
77.4%
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Obstetrics and Gynecology 2001;97:533
Maternal Hypertension in 1999-2005
All maternal hypertension identified at time of hospitalization for
labor and delivery (includes pre-gestational and gestational hypertension)
Source: http://www.cdph.ca.gov/programs/mcah/Documents/MO-CAPAMRTrendsinMaternalMorbidityinCalifornia-1999-2005-TechnicalReport.pdf
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Maternal Morbidity Based on Mortality
Approx. 8 Preeclampsia Related Mortalities / Year in CA
Near Misses: 80
1x
10x
100x
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Serious
Morbidity: 800
• Goal: Eliminate
preventable
maternal death &
injury & promoting
equitable maternal
care
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Resources
Tools
Measures
Quality
improvement
techniques
What are the goals for Preeclampsia
Collaborative?
– Early recognition of elevated BPs
(re-check, notify physician)
– Early and aggressive treatment
(anti-hypertensives)
– Staff education
– Patient education and timely follow-Up
– Patient Outcomes: Showing reduced rate of
morbidities, complications & extended LOS,
improved patient education
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If Only We Knew -The Quest to
Conquer Preeclampsia
If Only We Knew
(video)
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Preeclampsia Collaborative Participants
Northern CA
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Alta Bates Summit
Contra Costa Regional Med Ctr
Doctor’s Hospital of Modesto
John Muir Medical Center
Kaiser Hayward
Kaiser Oakland
Kaiser Roseville
Kaiser Santa Clara
Mercy San Juan Med Center
NorthBay Medical Center
Salinas Valley Memorial
Sonora Regional Med Center
Sutter Medical Center
Southern CA
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Arrowhead Regional Med Ctr
Cedars Sinai Med Center
Citrus Valley Med Center
Henry Mayo Newhall Memorial
Kaiser San Diego
Kaiser West LA
Long Beach Miller
Riverside County Regional Med Ctr
St. Jude Medical Center
Saddleback Memorial
UCLA
St Bernardine Medical Center
• MIHS~Phoenix,AZ
9 California & ONE Arizona hospital representing ~ 82,000 births in 2011 (1:6
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Why is MIHS participating in the
Collaborative?
• The primary aim of the Preeclampsia
Collaborative is to help reduce the rate of severe
morbidities in women with any hypertension &/or
severe preeclampsia/eclampsia & to reduce a
significant portion of complications & extended
hospital stays with the use of tools & guidelines
developed to support early recognition,
diagnosis, treatment & management of
preeclampsia & triggers requiring immediate
evaluation.
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MIHS Exceeds Target Rates
• California has a target of
8.8% for severe morbidity
(complications) with
hypertension.
• MMC/MIHS has
consistently performed
better than the target rate
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Severe Morbidity with Preeclampsia:
Jul 2012-Jan 2013
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Timeline
Jan 2013
Feb 2013
Mar 2013
Apr 2013
May 2013
July 2013
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• Comprehensive model for treatment developed @ MMC
• CMQCC Pre-eclampsia Task Force (first meeting)
• MMC OB Skills Fair
• Revised Pre-eclampsia debrief form
• Pocket medication cards made/distributed
• ASCOM Phones implemented for emergencies
Timeline, continued
Sept 2013
Oct 2013
Jan 2014
Feb 2014
Mar 2014
Future
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• MMC presented successes at CMQCC Mtg in CA
• Pregnancy Induced Hypertension Training
• CMQCC Tool Kit available on website: FREE!
• CMQCC wins ACOG award for Tool Kit
• MMC OB Alert Drills with simulation
• Ongoing unannounced drills, training
NICE Guidelines
• Recommendation 7: Systolic hypertension
requires treatment
– 7.1 All pregnant women with pre-eclampsia and a systolic blood
pressure of 150-160 mmHg or more require urgent and effective
anti-hypertensive treatment in line with the recent guidelines
from the National Institute for Health & Clinical Excellence
(NICE)3. Consideration should also be given to initiating
treatment at lower pressures if the overall clinical picture
suggests rapid deterioration and/or where the development of
severe hypertension can be anticipated. The target systolic BP
after treatment is 150 mmHg.
From CMACE 2011 report of maternal deaths from 2006-2008
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BP Treatment
Systolic
≥ 160
Diastolic
≥ 105
Treatment within
15-30 min
Gestational HTN =
Preeclampsia =
Severe Preeclampsia =
ECLAMPSIA
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Key Points
• Detect elevated BP in perinatal period
• Take BP in a seated or semi-fowler’s position
• If elevated (>=160 systolic OR >=105 diastolic),
repeat in 10 minutes
• If remains elevated, notify physician within 5
minutes
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Key Points continued
• Antihypertensive meds administered within 30
minutes
• Patients that are discharged having had
elevated BP, follow up reevaluation w/n 7 days
• Discharge teaching instructions provided
regarding signs & symptoms of preeclampsia
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Comprehensive Educational
Model Developed
• Nursing Leadership
Team
– Clinical Educators
– Nurse Managers
– Clinical Resource
Leaders
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PIH Training Model Platform
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10 offerings of class (3 hour each)
Pre-test
Didactic lecture
Demo/return demo: physical assessment & pump set-up
4 Standardized patient simulation scenarios
Post-debriefing with all scenarios
Post-test
Evaluation
Class Training Objectives
• Identify expected clinical findings during health
assessment of patient presenting with PIH
• Recognize symptoms associated with
Magnesium toxicity
• Assess various patient scenarios in real time
simulation, by evaluating and implementing
appropriate nursing interventions
• Demonstrate use of SBAR Communication with
team members
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Didactic Lecture Content
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Normal Physiology, S/S Pre-eclampsia
Lab Testing / Values
Intrapartum & Postpartum Management
Pharmacologic Interventions
Eclampsia, HELLP
CMQCC
Practice Changes
Practice Changes
• Magnesium Sulfate
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• Labeling Tubing
Standardized Patients & Confederates
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Standardized Patients & Confederates
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Suspend disbelief > promotes realism
Proper training > enhances emotional fidelity
Guide scenario-specific tasks > meet objectives
Bring to life the lesson intent > believability
Experiential learning > risk free environment
Show Time!
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Pregnancy Induced Hypertension
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Props and Costumes
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Bridge the gap
Cue cards
Helping cues adapted to match learner’s path
Assigned actual learners roles
Minimize uncertainty: Orient learner to
learning environment, props, characters,
boundaries and maximize real-time
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Eclampsia
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Simulation is the Perfect Stage!
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Real-time learning
Experiential, safe, supportive environment
Practice, observation
Commit errors without risk to patients
Feedback, reflection
Interpret and integrate knowledge, skills &
attitudes
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Magnesium Sulfate Toxicity
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Scenes and Scripts
• Based on specific learning objectives of the
simulation sessions
• Improvising is essential
• Connection between all participants
• Flexibility for rapidly changing circumstances
• Teamwork is key!
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Course Evaluations
• 52 nurses participated
• 51 of 52 passed post-test with scores of
90% or greater
• Summary evaluations = 4.9/5.0
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Severe Morbidity (excluding Hemorrhage)
with Preeclampsia: Feb 2013-Jan 2014
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Timely Treatment of Severe Hypertension
Jul 2012-Jan 2013
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Timely Treatment of Severe Hypertension
within 60 Minutes Follow Up 2/13-1/14
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Preeclampsia Collaborative
Maricopa Medical Center
2014 and Future
• Working on implementing new ACOG
recommendations
• Providers developing protocol to ensure
patients are seen for BP check within 3 days
postpartum
• Low-dose aspirin with history preeclampsia
• Plan to present case studies to ED providers to
stress importance of timely treatment and
consultation for preeclamptic patients
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Current Simulation Drills with
Standardized Patient
• OB Alert Training (online learning)
• Ongoing OB Alert Drills (un-announced)
– Emergency Department (more)
– On Postpartum Unit (May 2014)
– Cafeteria (June 2014)
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OB ALERT DRILL: ED
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Debriefing Points
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Debriefing Points, continued
• What went well 
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Debriefing Points, continued
• Teachable Moments…
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Debriefing Points, continued
• Room For Improvement!
– Management of OB patient in ED
– Familiarization with equipment
– Assign learning module to Physicians,
including Anesthesiologist and CRNAs
– System issues - correct overhead paging
– More un-announced drills!!!
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Preeclampsia Toolkit Wins ACOG Award
• https://www.cmqcc.org/preeclampsia_toolkit
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Share This Link!
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CMQCC Tool Kit
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Executive Summary
Clinical Pearls
Patient and Treatment Recommendations
Compendium of Best Practices
Algorithms
Appendices
Simulations/Drills
Slide set for Professional Education
Patient Education Materials
Multiple References
Sample from the kit
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Final Act!
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Differential Diagnosis with History of
Methamphetamine Use
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Remember…
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This is why we do the work that we do!
Thank you!
susan.pinto@mihs.org
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References
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American College of Obstetricians and Gynecologists’ Report (2013) Task
force on hypertension in pregnancy, Vol 122, No. 5
Baile, W., Blatner, A. (2014) Teaching communication skills using action
methods to enhance role-play in problem-based learning. Soiciety for
Simulation in Healthcare, Vol.00, No.00
Fanning, R., Gaba, D., (2007) The role of debriefing in simulation-based
learning. Society for Simulation in Healthcare, Vol.2, No.2
Gilbert, E.S. (2007). Manual of high-risk pregnancy and delivery. Fourth
Ed. Mosby: Missouri.
http://www.cdph.ca.gov/programs/mcah/Documents/MO-CAPAMRTrendsinMaternalMorbidityinCalifornia-1999-2005-TechnicalReport.pdf
CMQCC http://www.cmqcc.org/preeclampsia_toolkit Improving health
care response to preeclampsia: a california quality improvement toolkit
CMQCC
Mandeville, L.K. & Troiano, N.H. (1999). AWHONN High-Risk and Critical
Care Intrapartum Nursing, 2nd Edition. Lippincott: Philadelphia.
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References, continued
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Mattson, S. & Smith, J. (2004) Core curriculum for maternal-newborn
nursing, third edition, Elsevier Saunders, St. Louis MO.
Preeclampsia Foundation http://www.preeclampsia.org/thenews/videos/video/if-we-only-knew-the-quest-to-conquer-preeclampsia
Sanko, J., Shekhter, I., et. al. (2013) Establishing a convention for acting
in healthcare simulation merging art and science. Society for Simulation in
Healthcare, Vol.8, No.4
Shield, L. (2013) California maternal quality care collaborative and
preeclampsia expert panel