Jennifer Frost

The national partnership for maternal safety

Recognition of the need to reduce maternal mortality and morbidity in the United States has led to the creation of the National Partnership for Maternal Safety. This collaborative, broad-based initiative will begin with three priority bundles for the most common preventable causes of maternal death and severe morbidity: obstetric hemorrhage, severe hypertension in pregnancy, and peripartum venous thromboembolism. In addition, three unit-improvement bundles for obstetric services were identified: a structured approach for the recognition of early warning signs and symptoms, structured internal case reviews to identify systems improvement opportunities, and support tools for patients, families, and staff that experience an adverse outcome. This article details the formation of the National Partnership for Maternal Safety and introduces the initial priorities.

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism.

Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women’s Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into four domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.

National Partnership for Maternal Safety: Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period

Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.

Screening for Urinary Incontinence in Women: A Recommendation From the Women's Preventive Services Initiative

Urinary incontinence, the involuntary loss of urine, is characterized by 3 main types: urgency, stress, and mixed (1). Affecting an estimated 51% of women overall, urinary incontinence increases in prevalence with age, ranging from 13% in young, nulligravid women to 25% in reproductive-age, 47% in middle-age, 55% in postmenopausal, and 75% in older women (24). These rates are twice those reported in men (3). Of women with symptoms, 32% to 51% have episodes daily and 20% to 32% weekly (5). In a national survey, symptoms of incontinence were reported by 44% of white, 29% of African American, and 35% of Hispanic women (5). Urinary incontinence adversely affects a womans physical, psychological, and social well-being by limiting participation in social gatherings and work activities, interfering with sexual function, and reducing independence (6). Associated medical conditions include urinary tract infections, skin ulceration, and fractures resulting from falls occurring at night or while rushing to avoid urge incontinence episodes. Obesity (79) and a history of vaginal delivery (10) are important risk factors for urinary incontinence. Symptoms also are associated with potentially modifiable factors, such as smoking, caffeine consumption, diabetes, depression, vaginal atrophy, and constipation (11), as well as other factors, including menopausal status, hysterectomy, cognitive and functional impairment, and chronic medical conditions (12). In the United States, the direct cost of urinary incontinence care is approximately

National Partnership for Maternal Safety: Consensus Bundle on Venous Thromboembolism

19.5 billion (13), with direct medical and nonmedical costs of

National Partnership for Maternal Safety: Consensus Bundle on Safe Reduction of Primary Cesarean Births—Supporting Intended Vaginal Births

51.4 billion (14). Approximately 6% of nursing home admissions of older women are attributed to urinary incontinence (15), costing

National Partnership for Maternal Safety: Consensus Bundle on Safe Reduction of Primary Cesarean Births- Supporting Intended Vaginal Births

3 billion per year (15). Despite its high rates and adverse effects on health, well-being, and function, urinary incontinence is underreported by women and therefore infrequently recognized by clinicians. In a survey, approximately 55% of women with urinary incontinence did not report symptoms to their health care providers (6) because of embarrassment, stigma, or acceptance as normal. However, symptoms may be treated by behavioral, nonpharmacologic (16), pharmacologic (1618), and surgical interventions, depending on the type and severity of incontinence and patient preferences. Early intervention may reduce symptom progression, improve immediate and long-term quality of life, and limit the need for more complex and costly treatment (19). Womens Preventive Services Initiative The Womens Preventive Services Initiative (WPSI) is a national coalition of 21 health professional organizations and patient representatives that develops, reviews, updates, and disseminates evidence-based clinical recommendations for womens preventive health care services in the United States (20). The WPSI is supported by the U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA), and is led by the American College of Obstetricians and Gynecologists (ACOG). It was launched in 2016 to continue the work of the former Institute of Medicine (IOM) (now the Academy of Medicine) Panel on Preventive Services for Women (21), which issued 8 clinical recommendations in 2011 that were accepted for coverage and implementation under the Patient Protection and Affordable Care Act (22). The prevention services mandate of the Affordable Care Act requires covered services to be incorporated into private and public insurance benefits, with no cost sharing or deductible charges to patients (22). Similar to the IOM panels guidelines, WPSI recommendations are intended to guide clinical practice and coverage of services for the HRSA and other stakeholders. Initial WPSI work focused on reviewing and updating the IOM recommendations, and these updates were adopted by the HRSA in December 2016 (23). The WPSI will review its recommendations every 5 years and at any time relevant new evidence becomes available. The WPSI focuses on gaps in current prevention recommendations for women. These include services that the U.S. Preventive Services Task Force (USPSTF) considered but for which it provided indeterminate recommendations, such as grade C (provide service for selected patients depending on individual circumstances) and I (insufficient evidence to assess benefits and harms) (24). Additional gaps include existing recommendations with a narrow scope, areas with new research, and topics not addressed by other guideline groups. The WPSI bases its recommendations on evidence of both benefits and harms of an intervention or service and an assessment of the balance between the two (25). Cost is not considered in assessing a service. The WPSI recognizes that many of the most important clinical questions regarding effective use of preventive services are not addressed by research studies, particularly those involving adolescents, pregnant and postpartum women, or elderly women. In these cases, compelling indirect data also are considered to determine benefits and harms. The WPSI based its rationale for urinary incontinence screening on several considerations. Screening has the potential to identify urinary incontinence in many women who silently experience its adverse effects but may benefit from appropriate evaluation and treatment. Effective screening may lead to earlier or more timely treatment, including behavioral, medical, and surgical interventions, depending on the patients age and the type and severity of symptoms. Recommendation Focus and Target Population This is a new recommendation based on evidence of the benefits and harms of screening for urinary incontinence in women, including a new systematic review of the accuracy of screening instruments (26) and recently published systematic reviews on the benefits and harms of treatments. The evidence on urinary incontinence screening was not evaluated previously in a scientific review, and no clinical practice guidelines exist for screening. Previous guidelines developed by different professional organizations (12, 16, 18, 27, 28) addressed women with symptoms who are referred for diagnostic evaluation and treatment, not screening. The target audience for this recommendation includes all clinicians providing preventive health care for women, particularly in primary care settings. This recommendation applies to women of all ages, as well as adolescents. Methods WPSI Topic Selection and Recommendation Development The Evidence-based Practice Center methods of evidence review (25) are adapted from the USPSTF (29) and the previous IOM Panel on Preventive Services for Women (21). Details on methods, processes, and funding are available on a public Web site (20). The WPSI is overseen by an advisory panel of representatives from ACOG, the American Academy of Family Physicians, the American College of Physicians, and the National Association of Nurse Practitioners in Womens Health, representing most womens health care providers in the United States (Figure). In addition, 3 experts in womens preventive health care and evidence review serve on the advisory panel. Members of the Multidisciplinary Steering Committee are invited representatives of 21 womens health professional organizations and patients who select topics and develop and vote on recommendations. A separate Implementation Steering Committee plans dissemination. Scientific review of evidence is conducted by the Pacific Northwest Evidence-based Practice Center Committee, and conflicts of interest are evaluated before appointment and annually by the advisory panel, which determines eligibility for participation after an ACOG process. Figure. Organizational structure of the WPSI. AAFP= American Academy of Family Physicians; ACOG= American College of Obstetricians and Gynecologists; ACP= American College of Physicians; EPC= Evidence-based Practice Center; HRSA= Health Resources and Services Administration; IOM= Institute of Medicine; NPWH= National Association of Nurse Practitioners in Womens Health; WPSI= Womens Preventive Services Initiative. The WPSI selects topics that fill gaps in existing screening and prevention guidelines and that meet eligibility criteria. Criteria include conditions that affect a broad population of women; that are specific, more common, more serious, or differ in women; and for which prevention would have a large potential effect on womens health and well-being. Additional criteria require that the health service be a primary or secondary prevention service feasible for practice in the United States, including screening, counseling, immunization, and preventive medication or therapy, and that the quality and strength of evidence directly or indirectly support its effectiveness. The topic of urinary incontinence screening was selected by a vote of the Multidisciplinary Steering Committee members. The scope and key questions were developed by the advisory panel with additional input from subject experts. A systematic review addressing the key questions was conducted by the Pacific Northwest Evidence-based Practice Center and presented to the WPSI Multidisciplinary Steering Committee at an in-person meeting (26, 29). Members discussed the strengths and limitations of the evidence for urinary incontinence screening, including weighing the benefits and harms. The committee considered the quality and applicability of direct evidence indicating benefits and harms of screening on health outcomes, indirect evidence of the validity of screening instruments, and the effectiveness and adverse effects of treatments for urinary incontinence. Health outcomes included improved symptoms, function, and quality of life. Indirect evidence was used to link screening and health outcomes in the chain of evidence that might support screening in the absence of direct evidence. The committee also considered the effect of screening on symptom progression and avoidance of costly and complex treatments, as

ATRIAL FIBRILLATION GUIDELINE SUMMARY

Obstetric venous thromboembolism is a leading cause of severe maternal morbidity and mortality. Maternal death from thromboembolism is amenable to prevention, and thromboprophylaxis is the most readily implementable means of systematically reducing the maternal death rate. Observational data support the benefit of risk-factor-based prophylaxis in reducing obstetric thromboembolism. This bundle, developed by a multidisciplinary working group and published by the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care, supports routine thromboembolism risk assessment for obstetric patients, with appropriate use of pharmacologic and mechanical thromboprophylaxis. Safety bundles outline critical clinical practices that should be implemented in every maternity unit. The safety bundle is organized into 4 domains: Readiness, Recognition, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged.

TREATMENT OF HYPERTENSION IN ADULTS OVER AGE 60 TO HIGHER VS LOWER TARGETS: A CLINICAL PRACTICE GUIDELINE FROM THE AMERICAN COLLEGE OF PHYSICIANS AND THE AMERICAN ACADEMY OF FAMILY PHYSICIANS

Cesarean births and associated morbidity and mortality have reached near epidemic proportions. The National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care responded by developing a patient safety bundle to reduce the number of primary cesarean births. Safety bundles outline critical practices to implement in every maternity unit. This National Partnership for Maternity Safety bundle, as with other bundles, is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Bundle components may be adapted to individual facilities, but standardization within an institution is advised. Evidence-based resources and recommendations are provided to assist implementation.