Nancy Maratea, RN, goes through the Heart Safe Motherhood Program brochure with a newly-enrolled patient at Chester County Hospital.
As many as one in 12 pregnant women suffer from preeclampsia, which causes high blood pressure during pregnancy and leading up to delivery.
"Preeclampsia is on the rise here and across the country," explains Cathleen M. Brown, DO, site director for obstetric hospitalists at Chester County Hospital. While the condition tends to subside upon delivery, blood pressures can worsen even after giving birth.
If a woman's blood pressure remains elevated, or surges, during the first week after delivering, and if she's not being properly monitored, she's at increased risk of experiencing a seizure, stroke, heart attack, organ damage, developing heart disease, going into a coma, or even dying. But a first-of-its-kind program created by Penn Medicine has radically altered how the increasingly common condition is treated.
Heart Safe Motherhood enables doctors to monitor new mothers with high blood pressure remotely, from the comfort of their own home. The program was developed at the Hospital of the University of Pennsylvania (HUP), where it is now the standard of care for obstetric patients because data showed it reduced the need for patients to be readmitted with complications. In May, Chester County Hospital became the fourth Penn Medicine hospital to employ the text message-based program.
Expanding the availability of Heart Safe Motherhood is just one part of a multi-pronged effort to standardize maternal healthcare across the health system; by ensuring that proven safe practices are carried out consistently everywhere helps improve outcomes for all patients, as well as to reduce racial inequities. Elizabeth Howell, MD, MPP, chair of Obstetrics and Gynecology in the Perelman School of Medicine, has described the health system's dedicated efforts to improve pregnancy and birth outcomes as "a unique opportunity to meet the moment at a transformational point in our patients' lives" and an important foundation for setting up healthy communities.
At Chester County Hospital, Heart Safe Motherhood was first made available during the summer to eligible patients in the hospital's OB-GYN Clinic, which provides reduced-rate gynecology care, affordable prenatal care, and childbirth deliveries to uninsured and under-insured women.
"This program has tremendous value because it improves our ability to follow-up with this high-risk segment of patients while streamlining their access to care," says Brown.
Four hospitalists, including Brown, are responsible for managing Heart Safe Motherhood at Chester County Hospital. The team was brought to Chester County Hospital in July 2019 under the mission of elevating safety and quality of care in the hospital's labor and delivery unit. Implementing this program is one of several initiatives led by the hospitalists.
"We saw that patient outcomes improved across Penn Medicine as a result of the program," Brown says. "So we wanted to implement it as soon as we could with the goal of also reducing readmissions for moms who have hypertension."
"We decided to start with the clinic population because it is a small group, easy to follow, and it would give us the opportunity to test the workflow before we rolled it out to the larger patient population. The patients seen in the Clinic also have a higher instance of developing hypertension prenatally and in the postpartum period. Rolling the program out in this setting primarily was also beneficial because there is a high percentage of Spanish-speaking patients, which required us to develop Spanish text messages. When we expand to our general OB population we will have already had the opportunity to trial and tweak both the Spanish and English text scripts for health literacy. The initial implementation has gone well and we have now expanded the program to an additional practice under the hospital's umbrella," says Patricia (Trish) Ward, MSN, RNC-OB, clinical manager of the Mother and Baby Pavilion at Chester County Hospital.
The program will eventually be made available to all eligible patients at Chester County Hospital, as Penn Medicine is continuing to expand the availability of Heart Safe Motherhood to more patients in more places.
How a Cuff and Some Texts Protect Moms and Keep Families Together
As part of the Heart Safe Motherhood program, Nancy Maratea, RN, demonstrates the proper way to use a blood pressure cuff.
Before Heart Safe Motherhood, clinic patients diagnosed with preeclampsia or another pregnancy-related blood pressure disorder were asked to schedule a follow-up within a week of their delivery to have their blood pressure checked. In general, this is a best practice — all people who recently gave birth should see their OB-GYN within a week or two after childbirth for follow-up care. But seven out of 10 women who have high blood pressure during pregnancy skip their postpartum blood pressure check.
Heart Safe Motherhood allows for even closer monitoring while removing many of those barriers. Before being discharged from the maternity unit, the patient is trained to use a blood pressure cuff they will take home and enrolled in a program that enables them to receive text messages from their care team.
Once home, patients receive two automated text reminders for the next 10 days -- one in the morning and one at night—to check their blood pressure and text back their numbers. They'll receive an immediate text response, informing them if their blood pressure is normal or high. If it's high, the patient may be asked to take additional readings. When it's necessary, an obstetric hospitalist will contact the patient to discuss next steps.
If appropriate, the hospitalist can prescribe medications remotely, enabling the patient to remain at home with her new baby.
"Before, if a patient was diagnosed with high blood pressure and they were sent home with medication, they might still experience a surge in their blood pressure and need to come back to the hospital for management. That could mean being separated from their newborn," Brown says.
How Chester County Hospital Got Ready For The Next Evolution
Kathleen Macagnone, MSN, RN, Chester County Hospital Mother and Baby clinical educator, was charged with training the Chester County Hospital obstetric nurses in how to use the program. This began in July 2020, with formal instruction taking place in October. Among the most important of the nurses' responsibilities is identifying eligible patients, according to Macagnone.
"The first point of identification is the clinic itself. The next is the labor room. There, the nurses or a hospitalist can identify a patient. If a nurse does it, they’re supposed to alert a hospitalist, who can confirm the diagnosis and enroll the patient in the program," she says. "The final point of identification is the postpartum unit."
The nurses also come together during a shift and update each other on their patients, a practice called "“huddling". Should someone mention a patient with high blood pressure, the other nurses have been trained to ask if they’ve been considered for enrollment in Heart Safe Motherhood.
Once a patient is enrolled, the nurses are also responsible for explaining to them how it will work, providing them with the cuff, and educating them on how to use it. Macagnone says no further training will be necessary for the nurses as the program expands at Chester County Hospital.
"This program is a way for us to keep families together, improve compliance and, ultimately, patient outcomes."