Diagnosis of Pre-Eclampsia

Abstract

For pregnant patients diagnosed with preeclampsia Magnesium sulfate, nifedipine or given hydralazine is provided to improve the outcomes of mothers and babies from birth to 96 hours of life. Studies reflect that a proper algorithm can be used to diagnose the mother in order to differentiate labor from pre-eclampsia. The focus of this review is the impact of babies whose mother’s suffered from preeclampsia and were provided magnesium sulfate to help manage it. An algorithm for antihypertensive treatment of pre-eclampsia is provided based on the results from a recent study. Patients who followed the regiment of prescriptions for preeclampsia experienced lower seizure levels and birthed healthier babies. Despite these benefits, the drawbacks of medicinal support for preeclampsia must be evaluated and continuously monitored in order to decrease risk and maintain a balance. The paper reflects a literature review and analysis on the subject and also provides recommendations and the implementation plan for a proposed solution in order to incorporate the algorithm into processes and educational materials. In short, teams must be established in order to manage integration of this algorithm in order to create a best practice standard in order to improve the health outcomes of mother and child.

Introduction

Preeclampsia is a common but dangerous disease. It affects five to eight percent of pregnancies and is the cause of eighteen percent of maternal deaths in the United States (PF, 2002). The following will discuss the outcome of babies and mothers who have been placed on Magnesium sulfate, nifedipine or given hydralazine as a result of being diagnosed with preeclampsia in pregnancy. A literature review and study is completed to determine if there is the potential for an algorithm that can be applied to differentiate labor from pre-eclampsia. Through research, it is found that a proper algorithm for diagnosis can be useful in differentiating labor from pre-eclamsia and allows health professionals to correctly treat and medicate affected patients without forcing delivery. 

Problem Statement

The issue regarding preeclampsia is that there is no specific determination test to diagnose it. Doctors and nurses must be diligent in their approach of it and continuously check the patient for high blood pressure and high levels of protein in the urine. An algorithm is necessary to help health care professionals identify this issue and differentiate its symptoms from those of typical pregnancies. The diagnostic algorithm must extend to a treatment phase in order to address the outcome of patients and babies up to 96 hours after birth, which is a significant purpose of this study.

Theory and Rationale

The theory is that by incorporating algorithm of test standards and symptoms, health professionals will be able to differentiate preeclampsia and begin to treat it early. This will give the patient and the fetus a better chance of maintaining health and well-being while making it easier for nurses to treat them appropriately. By medicating the patient with options such as Magnesium Sulfate, nifedipine or hydralazine, the negative effects of preeclampsia can be regulated long enough to avoid an unsafe early delivery (Munjuluri et al., 2005). The rationale for this theory is deeply rooted in research and scientific study which purports the benefits of these drugs in managing the issue and helping to keep mother and child healthy even after delivery. It is recommended to incorporate this diagnostic algorithm into health care practices by educating hospital staff and nurses through training and development. Human resource management will be used to support staff development and empower the hospital team to ask questions and take ownership of patient needs. This will allow preeclampsia patients to be effectively monitored and increase awareness of the diagnostic and treatment procedures necessary to manage the issue. Human resource management theory helps to support the proposed solution of additional training and development because its foundation seeks to maintain trust and relationship with employees. As training and development can be expensive, it is necessary to apply strategies that will increase morale and support nurses and doctors. Being available for questions and feedback offers support that will encourage nurses to remain in the facility and go above and beyond for the customer. While the goal is to incorporate this algorithm through training and development, human resource management cannot be overlooked as a necessary management tactic to support this proposed theory and solution in the health care firm.

What is Pre-Eclampsia

Pre-eclampsia is hypertension and high blood pressure induced by pregnancy. It is a dangerous condition that can be life threatening for both the mother and the fetus, and can lead to intrauterine growth restrictions and preterm infant births. When severe, pre-eclampsia causes a diastolic blood pressure of 110 Hg or more, with a systolic blood pressure of 160 Hg or more (Alanis, Robinson, Hulsey, Ebeling & Johnson, 2008). Exess protein in the urine will also be detectable after twenty weeks of pregnancy, even if the mother’s previous blood pressure was normal. Patients will experience severe headaches, vision changes such as blurred or loss vision and upper abdominal pain. Nausea and vomiting, dizziness, decreased urine and sudden weight gain are also common symptoms. In addition, while swelling can occur in normal pregnancies, it often accompanies preeclampsia and particularly affects the patients face and hands. Symptoms can also include biochemical or haematological impairment (Huppertz, et al., 2013). Aside from this, the baby may develop neurological damage induced by hypoxia as a result of the high blood pressure environment in the womb. As it is so dangerous, common, and can be deadly and lead to long term impact, it is essential to recognize pre-eclampsia early in in order manage it effectively (Hibbard & Rosen,1977). Slight increases in blood pressure can be a sign of the issue and must be monitored and evaluated consistency. Pregnant women should be checked often to identify any potential signs of clinical deterioration such as platelet count reduction in blood cells. In order to avoid serious consequences, early detection is necessary to avoid serious consequences and complication for mother and child. Being diagnosed with preeclampsia early on in the pregnancy is extremely dangerous because it carries a more significant risk than if the mother was near the end of her pregnancy. Any issues that occur during the developmental phase of the fetus is extremely dangerous and can have long term effects. 

The Effect of Medicine on Preeclampsia outcomes

While researchers have not definitively determined exactly what causes Preeclampsia, possible causes include poor diet, blood vessel damage, immune system problems, and insufficient blood flow to the uterus. While the only final cure for preeclampsia is to deliver the baby, patients diagnosed early have an increased risk of stroke, seizure, and placental abruption. When delivery is not an option medications to lower blood pressure will be provided to address the problem until delivery. These medications are known as anti-hypertensives as they address the increased hypertension caused by preeclampsia (Andraweera, Dekker & Roberts, 2012). Corticosteroids are also used in severe cases in order to manage liver and blood platelet function. This also contributes to lung maturity in babies; giving them a better chance of surviving outside of the womb should delivery become necessary.

Magnesium Sulfate

Anticonvulsive medications will also be used if the preeclampsia is very severe. Magnesium sulfate is often used to prevent eclamptic seizures. Studies published by the American Heart association show that this drug is effective as an anticonvulstant and can positively impact cerebral vasolidation, and support blood-brain barrier protection (Duley, 2008). The medicine acts as a type of vasodilator, helping to decrease peripheral vascular resistance and relieve constriction in the vascular area. Its impact on the blood-brain barrier helps to limit formation of cerebral edema, allowing the patient to stay regulated and prevent convulsions. It can also be used to stop seizures while they are occurring and prevent repeat attacks. Despite these benefits, doctors have safety concerns regarding the use of Magnesium sulfate related to the potential for hypermagnesemia toxicity which can lead to cardiac arrest (Aya, Mangin, Hoffet, & Eledjam, 1999). Standard infusion protocols help to maintain the safety of the patient while managing the effects of preeclampsia. While it may not be effective in treating all eclampsia cases, Magnesium Sulfate provides a positive outcome for the mother and the fetus if regulated appropriately. 

Magnesium sulfate can be given two different ways. It is typically given intravenously through an IV, but can also be directly injected into a muscle. The intravenous process is less painful and does not need to be given as frequently as the muscle injection. Despite this, if a reliable IV is not available or continuous monitoring is not possible the muscle injection must be applied (Duley, 2008). Patients may experience low energy levels and muscle weakness, slurred speech and blurry vision after taking Magnesium Sulfate. Headaches, nausea, vomiting and stuffy noses are also common side effects. As a whole Magnesium sulfate is an effective treatment for preeclampsia because it prevents seizures and carries small risk if standard infusion protocols are used. In addition, the side effects are not unreasonable given the fact that the medicine provides safe and positive outcomes for the mother and her child.

Nifedepine and Hydralazine

In clinical trials, patients who experienced severe preeclampsia were given nifedepine and Hydralzine separately. The studies show that patients who received nifedipine experienced effective control of blood pressure 95.8% of the time. Of the patients who were given hydralazine, only 68% of patients experienced a statistically significant difference in blood pressure and control (Fenakel, Fenakel, Appelman , Lurie , &, Shoham, 1991). In addition, babies born to mothers treated with nifedipine weighted more, were delivered at more advanced and safer stages, and also had fewer complications. When complications did arise, they were minor. Compared to hydralazine, the average number of days the newborns spent in the intensive care unit was significantly lower and led to an average of a 31% reduction of hospitalization (MTFSMG, 2004). In addition, this medication has a relatively low cost and does not result in undesirable side effects. As a result, nifedepine is an effective source of treatment for mothers and babies and continues to be beneficial up to 96 hours of birth by regulating blood pressure. While those in the hydralazine group did not have negative outcomes, the effectiveness was significantly lower than when nifedepine was used. 

Nifedepine is the best choice of action for patients with preeclampsia. This medication should be used to manage high blood pressure while Magnesium sulfate should be used to manage potential seizure symptoms. As discussed, patients using these medications increase their chances of delivering healthy babies within a safe gestational period. While bed rest may be initially suggested to lower blood pressure and increase placenta blood flow, severe preeclampsia must be addressed using this proposed combination. 

Diagnostics

There is currently no single test to diagnose pre-eclampstia. However, high blood pressure and the existence of protein in the urine are significant indicators. When patients have high blood pressure and protein in the urine it is standard to discuss with the patient whether they have experienced headaches or abdominal pain (Uzan, Carbonnel, Asmar, Ayoubi, 2011). As labor symptoms and normal pregnancy side effects can be similar to pre-eclampsia symptoms, the diagnostic algorithm must place emphasis on the blood pressure and urine protein to detect signs and monitor fetal development meticulously through fetal ultrasounds. 

Figure 1.0 shows the current accepted standard for diagnosing preeclapsia. The HELLP analogy algorithm helps to differentiate among disorders of hypertension in pregnant women. This acronym represents the Hemolysis, Elevated Liver enzymes and Low Platelet count symptoms which indicate the need for a preeclampsia diagnosis (Wagner, 2004). This algorithm is not currently standardized in the health care facility and lacks an additional treatment algorithm to support it. An implementation plan is necessary to incorporate this algorithm as standard best practice and supplement it with a treatment algorithm that regulates the use of Nifedepine and Magnesium sulfate. 

Implementation Plan

The plan to incorporate this theory is simple. First, necessary approval will be necessary in order to garner support from the organization’s leadership and staff. The first step will be to create and present a proposal discussing the benefits of the HELLP algorithm and the need for it to be incorporated into hospital systems. By explaining regional and hospital specific statistics, a case can be made to increase the awareness and best practices for identifying and treating preeclampsia. A full proposal, related to the training and development that will be necessary as well as the initial and maintenance cost involved will be essential to the proposal. It will also be necessary to provide graphed representations for how the current system of diagnosis has cost the hospital money as a result of its ineffectiveness. By showing numbers that reflect the bottom line results of a change in policy, the organization’s leaders and shareholders will be convinced of the need to incorporate this diagnostic algorithm into the hospitals best practices. Related to the accompanying algorithm for treatment, hospital staff will find it easy and simple to follow. This leads to fewer guesses and fewer overall mistakes. As hospital funding and profits directly relate to the hospitals rates of mortality, and quality of care, anything that helps to streamline diagnostic and treatment processes should be welcomed by partners and shareholders. This will be discussed with the nurse management team so that it can be reviewed and analyzed by a reputable peer group before it is presented in front of the hospital board. While obtaining necessary approval from the hospitals leadership staff will be challenging, it will be easier to secure staff support. 

Additional training and opportunity are a part of the standard foundations to incorporate human resource management. Especially in hospitals and health care facilities, where nurse recruitment and retention is problematic, training and development is welcome and appreciated. Additional training and exposure to this diagnostic algorithm will help nurses do their jobs better and feel confident that they are following standardized best practices. 

The proposal will outline the current scenario, which leaves diagnosis and treatment up to an arrangement of tests and symptoms. The formula for diagnosis based on these aspects varies from person to person because each individual is making their decision based on their personal experience and education. The problem is that there is no accepted streamlined process to differentiate preeclampsia from traditional pregnancy and labor symptoms that can be used as a standardized best practice throughout the hospital. A change in policy, which will train health care employees on standardized diagnostic procedures, will be helpful to decrease errors and streamline processes. Additional study can be undertaken to acquire data with which to provide a baseline comparison. Even without this information, health care leaders understand that streamlining processes puts less pressure on nurses and helps maintain a systemized flow of processes and resources within the facility.

The proposed solution is to incorporate the HELLP algorithm into standardized review for health care staff and also develop a treatment algorithm with which to refer. This new policy and process will need to be supported by additional education and training in order to provide a comprehensive understanding to staff. This will be accomplished by incorporating training for staff which will detail the algorithm and how to use it. A 2 day training session is proposed in order to explain the algorithm and advise staff that it will now be incorporated into best practices. Allowing time for questions and concerns will help staff to fully comprehend the new process and understand the benefits of following it as well as the consequences for ignoring it. The proposed solution will be presented to all members of the staff by an outside professional who is an expert in applying the HELLP algorithm. Funds will have to be set aside to compensate for this training and development opportunity. The cost involved may be decreased depending on the ability of the hospital to negotiate and partner with training corporations. 

Streamlined operations are beneficial to any organization and facility. Studies show that streamlined diagnostics and assessments help save facilities time and money by eliminating waste and providing a standardized process that is simple to follow and manage (Zhang, 2007). This evidence will support the proposed solution and solicit support for implementation of this diagnostic algorithm. This new policy will be discussed in the context of its ability to save lives, time and money by streamlining procedure. This has a positive effect on mothers and babies who are treated at the facility, and also has a positive effect on nurses and staff who are responsible for addressing patient symptoms and diagnosing preeclampsia. The leaders and shareholders for the health care organization also benefit by experiencing potentially lower maternal mortality rates, and delivering healthier babies. As these attributes can improve the facility’s ability to receive significant funding through personal and private grants, it will be well worth the initial training and development investment. The lives and money saved as a result of this streamlined process is the foundation for the rationale behind selecting this proposed solution. 

Logistically, this change will be implemented by bringing together hospital staff and directing them to a training room that has been prepared with educational materials and a presentation. If the board approves the process change the implementation can begin in one week following the approval. This will allow time to contact the training team and work out the financial cost to the training and development session. The team will be told that a professional is coming in to discuss the issue of diagnostics and treatment of preeclampsia in order to prepare them to be receptive of the new information. This third party trainer will be primarily responsible for educating staff in the training and development session. Health care management will be responsible for initiating that change and overseeing the implementation process. Guidelines will be integrated into employee standards and a check and balance system will be incorporated to maintain staff accountability. Nurses and health care staff will need to complete specially created forms on the patients chart showing that they reviewed all aspects of the algorithm for each patient. This can be done on the paper chart, however, staff will be advised to complete this information on the patient’s digital chart in order for it to be seamlessly integrated into the patients digital medical history and chart report. This will allow other medical professionals to view it easily and also contain valuable information for other facilities if the patient’s medical history has to be provided to another health care facility. Paper forms will only be accepted in extenuating circumstances where digital access was not available and the patient needed to be immediately seen. For one week after the training and developmental session, the hospital will designate a support team to provide assist those who have additional questions or concerns. In addition to the management staff, this team will be responsible for initiating the change, continuing staff education and overseeing the implementation process. By integrating this plan into the organizational structure of the facility, the nurses will feel more empowered with a supportive culture. In addition, the workflow will be streamlined and appropriately managed, decreasing staff stress and pressure.  

The resources required for implementation include staff educational materials such as pamphlets, handouts and posters. The PowerPoint presentation used in the initial presentation will be made available to staff after the session via the facilities website. It will be incorporated into the training and development section of the hospitals share point site in order to be readily available for staff that may have additional inquires or would like a presentation refresher. Pre and post tests will be used in conjunction with the training in order to determine how effective it was in educating staff and assess a knowledge baseline to calculate intervention effectiveness. Surveys will also be incorporated in order to determine how the staff felt about the training, the topic it covered, and their ability to manage more effectively as a result. Technology will play a large part in supporting required resources. Software and technology will allow the trainer to present with up to date information. This technology will also allow the facility to present the pre and post exams and surveys on iPads instead of on paper. This helps to streamline the documentation process and allows the computer to immediately calculate the results. Expedited tabulation of the results will also be beneficial because organizational leaders and shareholders will have a significant idea about the effectiveness of the training without having to wait. While continuous evaluation will ensue over a period of a few months, initial documentation and information will be exciting to share. As the hospital already has updated, innovative and cutting edge technology, the cost to integrate the presentation will be zero. Costs incurred in this process include the price of compensating a trainer to explain how the HELLP algorithm works and how to incorporate that into a treatment phase. The printing and production of education materials will also cost, however it will be relatively low because of the firm’s partnership with local printers. The gathering and analysis of data during and following implementation will not be very costly because the hospital has a very effective documentation system that can be manipulated to cross analyze and process data. In addition, the team assigned to oversee and evaluate change is already full time employees. This means that their contribution to this project will not impact the cost to the health care firm.

Methods

Methods to evaluate the effectiveness of the proposed solution and assessment of the project outcomes will include capturing staff attitudes related to job satisfaction before and after changes were initiated. This must be done over a period of one to six months in order to understand the short and medium term implications of the change. The facilities iPads will be used for this engagement survey and will be distributed every two weeks for up to months. This will provide a data trend to present to leaders and stakeholders regarding the effect of the implementation on staff morale and perceptions of empowerment. This survey process will also include a feedback section that allows staff to vent and be specific about what bothers them. While the job satisfaction and dissatisfaction outcomes will not be the only variable when accessing the success of the new policy, it is best practice to attempt to integrate policies while also supporting employees. When processes show a benefit to patients and the hospital and not a benefit to staff morale, it provides a learning experience. Human resource management practices should always be applied in order to alleviate low morale and frustration in the process of procedural change. In addition, when employees and staff feel empowered, the change almost always results in better patient quality and improved overall excellence. 

In order to create a baseline for employee morale and turnover related to the procedural change and training, it will be necessary to obtain turnover rates before and after initiating the change. The health care facilities innovative technological programs automatically capture turnover rate data, providing a helpful data resource for comparison, analysis, and review. Patient discharge surveys will also be evaluated before and after the change. The procedural change should improve diagnostic measures for not only pre-eclampsia but other prenatal diagnoses such as Tay-Sachs disease. There will also be an increase in the quality of care that mother and baby receive. Especially, related to diagnostics, medicinal treatment and care quality for the first few days of birth (96 hours), patients will be asked to complete discharge surveys in order to capture customer perspective related to the change. In short, staff attitudes and perceptions, patient attitudes and perceptions, and rate of nursing staff turnover are the most important variables to incorporate into review methodology. Each of these components is essential to understanding the implications of the change and provides valuable information to make adjustments and future changes. Understanding how each of these areas is affected will provide case study examples for the board to consider when new processes are proposed in the future. In addition, it provides potentially publishable data that can be used to highlight the hospitals practices and encourage new nurses to join the facility. In this way, positive change can address the problem of nurse recruitment and retention over the long run. Patients will also choose to attend the facility because of the positive reviews and the presence of additional qualified and empowered staff.  In this way the facility will benefit from helping internal patients, external patients, and promoting a stellar public relations review for its practices and procedures. 

Disseminating Results

Similar to the presentation of the initial proposal, the data for the results of the change will be presented to the leadership board for review. A presentation will be given to highlight the effect of the change on patient outcome and staff morale. As the financial element was so essential to the proposal piece, the result presentation will also focus a significant amount on the financial benefits of the change. This information will be integrated into a bound presentation which highlights the results of the study using qualitative and quantitative data. Visual graphs and other representations will be used in order to show each aspect of the change and the resulting impact on the hospital, its staff, and its patients. This information will be posted on the hospitals website and presented at the key stakeholder meeting. The greater nursing community will be exposed to this information through publicity garnered through the publication of this material. It will be published and posted in reputable journals in order to reveal the effects of the streamlined algorithm and training session on key stakeholders. Once this information is published, it is sure to garner significant positive public relations, resulting in news coverage and community discussion. The greater nursing community will hear about it through these means, increasing the chances that qualified nurses will attempt to look for positions. This will also instill pride and accomplishment into current nurse staff, causing them to maintain employment with the facility and make plans to spend their career with the organization. 

Conclusion

In conclusion, incorporating the HELLP algorithm into best practices in the health care facility will lead to streamlined diagnoses and improved patient care. Incorporated with treatment algorithms which include Nifedepine and Magnesium sulfate medications, the hospital can improve the health of patients and babies with preeclampsia. In implementing this process, it is important to apply human resource management theories in order to empower and engage employees. Streamlining processes in this way leads to exponential benefits for patients, staff, the community and other organizational stakeholders.

(Appendices: Figure 1.0 omitted for preview. Available via download) 

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