Postnatal hypertension made simple and sustainable (Green Maternity Challenge)

Project completed as part of the National Green Maternity Challenge 2024-25 by the team at Imperial College Healthcare NHS Trust.

Team members:

• Dr Thomas Liney, Specialty trainee in Obstetrics & Gynaecology
• Miss Kerry Munro, Consultant Obstetrician, and maternal medicine specialist
• Miss Taylor-Clarke, Consultant Obstetrician
• Dr Hannah Browne, Junior Clinical Fellow in Obstetrics & Gynaecology

Setting / patent group: Maternity Services

Issue: 

There is heterogeneity in prescribing and managing hypertension in the postnatal population at the Queen Charlotte’s & Chelsea Hospital postnatal ward. Post natal hypertension is a leading cause of postnatal readmission with far reaching environmental, equity and financial impacts. Poor treatment can prolong hospital stays, wastage of medications, increase in travel for follow up and emergency re-admissions. Poorly controlled blood pressure also increases patients’ lifetime risk of cardiovascular disease, leading to increased reliance on healthcare system. Furthermore, postnatal hypertension has also been recognised as an inequity issue, with black women having persistently higher blood pressure postnatally that took a longer time to return back to normal as compared to white women.

Intervention:

The main aim of this project was to streamline management pathway for postnatal hypertension, by improving protocols and reducing prescription heterogeneity, to reduce unnecessary inpatient stays, prevent readmissions, reduce medication waste and make it more sustainable. An audit was conducted to analyse prescriptions for postpartum hypertension patients and resident doctors were anonymously surveyed to determine their confidence in managing the condition. Followed by patient and GP feedback, a mini literature review was conducted and MDT discussion was organised. Based on this, a new flowchart and poster was designed and implemented, which clarified the length of stay, blood test criteria, first line medication and criteria to switch between various antihypertensives. These were made in image format for ease of access and all relevant practitioners were informed of the change in flowchart. A re-audit and re-survey were conducted at the end.

Outcomes:

Environmental

The carbon footprint per woman before the intervention was 205 kgCO2e. After the intervention the carbon footprint decreased to 88 kgCO2e, resulting in savings of 117 kgCO2e per patient. Extrapolating these figures to the average number of women affected by hypertensive disorders, there could be savings of 58,645 kgCO2e.

Social

The project will be able to reduce the negative impacts of prolonged hospital stays on patients such as poor sleep, feeling of isolation, pain due to blood tests, and poorer bonding with their

baby. Positive feedback was received from women and most residents found the new guidelines to be more useful and increasing their confidence in managing postpartum hypertension.

Clinical

The average stay of postpartum stay was reduced by 2.6 days on average, along with an average of 2.92 fewer sets of tests per patient conducted. 28% of patients were discharged with more than one antihypertensive before the intervention, while none of the patients were discharged on multiple antihypertensives post intervention. The need for unplanned reviews and readmissions could also be eliminated.

Financial

Following the intervention, the average cost of a 14 day prescription per patient was £2.46 as compared to £2.79 before the intervention, leading to a savings of £165 on discharge prescriptions alone, if implemented to all the women suffering from postnatal hypertension. With respect to blood tests, the average cost was reduced from £28.60 on average to £13 per patient. This has the potential to lead to savings of £14,300 from reducing the number of blood tests alone.

Key learning point:

The project focuses on an overlooked area of maternity care, and shows that improvements in that area can have long lasting impacts for patients and the NHS. By making small and inexpensive changes, clinical change can improve patient care while also having positive impact on the environment and financial costs.