Implementing an Antinatal Protocol to Screen for Preeclampsia Risk and Initiate Low-dose Aspirin Therapy

Preeclampsia (PE) is a hypertensive disorder that affects approximately 4% of pregnancies and is associated with higher maternal and fetal morbidity. It can progress to eclampsia-PE/eclampsia results in 6.4 per 10,000 maternal deaths annually. Current evidence indicates that routine screening to identify high-risk PE patients by 12-16 weeks gestation and initiating low-dose aspirin (LDA) can reduce PE by 18%. Not all OB providers adhere to screening recommendations and treatment. Local Problem: This project took place at a large practice of midwives and physicians who provide obstetric care for hundreds of women in Utah County. They do not have a standard protocol for PE risk factor screening, which can result in missed identification and treatment of high-risk OB patients, potentially leading to poor maternal and fetal outcomes. Methods: A review of provider schedules was performed to collect data regarding the number of new OB (NOB) patients eligible for screening. Providers' visit notes were reviewed to determine their current charting practices for NOB patients. A pre-intervention survey was administered to participating providers at a staff meeting to assess their understanding, attitudes, and knowledge of PE screening guidelines and their current clinical practices. A presentation regarding evidence-based PE screening and treatment guidelines was given at this meeting. A protocol was developed for universal PE risk screening, and the NOB note template was modified to incorporate the screening tool. At the conclusion of the project, participants completed a post- intervention survey. Feedback regarding the intervention's feasibility, useability, and sustainability was also obtained. Interventions: A protocol was developed and sent to all clinical staff. Medical assistants (MAs) provided patients with the PE risk factor form during rooming. They reported results to providers, who then documented risk factors in the note. Providers were instructed to counsel patients with risk factors during the first prenatal visit. Patients designated high risk were encouraged to initiate LDA at 12 weeks gestation. Providers then documented "high risk for PE" in the patient's problem list and added LDA to the medication list. Results: From January 12 to February 16, a total of 285 new OB patients were seen by the providers. A chart audit revealed that 157 (55%) patients had documented screening, and 128 (45%) patients did not have screening documented or had unclear documentation. Of those appropriately screened, 116 (74%) were designated low risk for PE and the remaining 41 (26%) patients were high-risk. Only 18 (44%) high-risk patients received appropriate counseling regarding their risk status and received a recommendation to start LDA at 12 weeks gestation. Conclusion: Providers showed a willingness to improve their screening of patients, although a very high percentage of charts did not show documentation of screening, counseling of PE risk, or documentation of LDA therapy. Providers expressed a desire to continue using the tool in practice. It will be important to replicate this project and evaluate the sustainability of the protocol over a much longer period.