Barriers to screening and intervention for ED patients at risk for undiagnosed or uncontrolled hypertension.

OBJECTIVES: We describe clinician-reported knowledge of the Joint National Committee (JNC7) on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure definitions of Stage I hypertension; perceived causes of elevated blood pressure; barriers to blood pressure re-assessment; risk of adverse events associated with the elevated blood pressure. METHODS: Health care providers from five emergency departments completed a questionnaire assessing knowledge of blood pressure criteria for hypertension, perceived causes of elevated blood pressures, barriers to re-assessment, and perceived risk of an adverse event at one year in a patient within three defined systolic and diastolic blood pressure ranges. Descriptive statistics were used to analyze the data. RESULTS: Seventy-two percent (379/524) of providers (68 attending physicians, 87 residents, 209 nurses, and 15 nurse practitioners) completed questionnaires. One hundred and four providers (27%) correctly listed the systolic and diastolic criteria for Stage 1 hypertension. Nurses and physicians rated uncontrolled, known hypertension [mean (standard deviation)] [8.7 (2.1), 8.9 (1.9)] the highest and pain [8.3 (2.3), 8.3 (2.1)] as the second highest cause of elevated BP. Nurses and physicians rated the lack of time to perform a reassessment [5.2 (3.4), 4.7 (2.8)] and a lack of adequate staffing [4.7 (3.4), 4.6 (2.9)] the highest as barriers to re-assessment. Nurses' mean adverse risk assessment twice that of physicians. DISCUSSION: Twenty seven percent of providers were aware of the JNC7 criteria and often attributed elevated blood pressures to chronic, uncontrolled hypertension, pain or anxiety. No single barrier to repeating elevated blood pressures was identified.

Evaluation, management, and referral of elderly emergency department patients with elevated blood pressure.

OBJECTIVES: To determine blood pressure (BP) reassessment rates and to describe the evaluation and outpatient referral rates of elderly emergency department (ED) patients with elevated BP. METHODS: This was a retrospective cohort of patients who were at least 60 years, presented with a systolic BP of at least 140 mmHg or diastolic BP at least 90 mmHg, and were discharged from the ED. BP measurements, ancillary testing, and discharge instructions were obtained from a random selection of medical records. RESULTS: Of 267 patients 198 (74%) underwent a BP reassessment. Factors associated with a reassessment included receipt of an antihypertensive, symptom of chest pain, care in an ED with a BP reassessment protocol, and increasing age. Of the 241 patients who maintained an elevated BP, 88 (37%) had no prior history of hypertension, 36 (15%) had a prior history but had untreated hypertension, and 117 (49%) had known, treated, but poorly controlled hypertension. Ancillary testing was completed on 144 (60%) patients and only 24 patients received an antihypertensive medication while in the ED. These patients had higher systolic (177 vs. 156 mmHg) and diastolic values (98 vs. 84 mmHg) than those who did not receive antihypertensive medications (P<0.01). At discharge, 29 (12%) patients received a directed referral and 28 (12%) received any intervention, with the provision of antihypertensive prescription the most common in 17 (7%). CONCLUSION: Unlike other ED-based studies of adult hypertensive patients, BP reassessment in the elderly occurred in the majority. Referral and intervention rates, however, were low.

Provider self-report and practice: reassessment and referral of emergency department patients with elevated blood pressure.

BACKGROUND: We attempted to identify patient factors associated with blood pressure (BP) reassessment and to compare health-care provider self-reported reassessment and referral to actual practice in an emergency department (ED) setting. METHODS: Provider reassessment and referral practices were determined through systematic review of 1,250 medical records at five EDs. Medical records were included if patients were > or =18 years, nonpregnant, presented with a systolic (SBP) > or =140 or diastolic BP (DBP) > or =90 mm Hg, and discharged. A separate questionnaire obtained self-reported practice patterns of health-care providers. Multivariate logistic regression identified factors associated with patient BP reassessment and referral. RESULTS: Of 1,250 patients, only 57% underwent BP reassessment and 9% received a referral for outpatient management. The most significant independent variables related to a reassessment were as follows: treatment of elevated BP in the ED (odds ratio (OR): 6.05; 95% confidence interval (CI): 1.80-20.31), chest pain (OR: 3.90; 95% CI: 2.37-6.42), and presence of an ED reassessment protocol (OR: 2.49; 95% CI: 1.77-3.50). The most significant factors associated with a referral included treatment of elevated BP in the ED (OR: 5.55; 95% CI: 2.72-11.32), presence of a reassessment protocol (OR: 2.58; 95% CI: 1.32-5.05), and a BP reassessment (OR: 2.56; 95% CI: 1.34-4.89). For self-reported practice patterns, 379 (72%) health-care providers completed questionnaires. Providers consistently overestimated their referral practices, yet the mean referral threshold values reported (SBP, 150 mm Hg; DBP, 93 mm Hg) were lower than the mean BP values of patients who actually received a directed referral (SBP, 170 mm Hg; DBP, 97 mm Hg, P < 0.0001). CONCLUSIONS: Reassessment and referral of discharged ED patients with elevated BP was infrequent and health-care providers overestimate their reassessment and referral efforts.

Knowledge translation of the American College of Emergency Physicians clinical policy on hypertension.

OBJECTIVES: To determine if dissemination of the American College of Emergency Physicians clinical policy on hypertension to emergency physicians would lead to improvements in blood pressure reassessment and referral of emergency department (ED) patients with elevated blood pressure. METHODS: Two academic centers implemented a pre-post intervention design, with independent samples at pre and post phases. ED staff were blinded to the investigation. A total of 377 medical records were reviewed before policy dissemination and 402 were reviewed after policy dissemination. Medical records were eligible for review if the patient was at least 18 years of age, was not pregnant, was discharged from the ED, and had a triage systolic blood pressure > or = 140 mm Hg or diastolic blood pressure > or = 90 mm Hg. Patient records with a chief complaint of chest pain, shortness of breath, or neurologic complaints were excluded. Demographics, blood pressures, and evidence of discharge referral were abstracted from the medical record. The policy was disseminated after the initial medical record review. Post-policy dissemination medical record review was conducted within two weeks. RESULTS: A total of 779 medical records were reviewed. The mean age of patients was 45 years, 55% were male, and 46% were white, 13% Hispanic, 35% African American, and 6% other. No differences in reassessment or referral rates were found between study phases. Blood pressure reassessments were low during both phases: 33% (pre) and 37% (post). Referral rates of patients with elevated blood pressure were very low: 13% (pre) and 7% (post). CONCLUSIONS: Knowledge of guidelines did not translate into changes in physician practice. Additional systems-based approaches are necessary to effectively translate guidelines into clinical practice.