Better Triage for Safer Care
Overly aggressive treatment of asymptomatic high blood pressure can lead to several side effects, from faint dizziness to life-threatening organ failure. Yet in hospital settings, hypertensive patients are frequently prescribed intravenous medications when oral agents would decrease blood pressure more slowly and safely, according to a research study from the Icahn School of Medicine at Mount Sinai.
Hypertension emergencies account for only 1-2 percent of hospitalized patients with high blood pressure, but they require the use of IV antihypertensive drugs to avert organ damage and possibly death. Hypertensive urgency, by contrast, can be caused by anxiety or pain and the recommended course of action is to use oral antihypertensive drugs over hours or even days to gradually reduce blood pressure.
At Mount Sinai Hospital in New York City, members of the High Value Care Committee and Student High Value Care Initiative identified the management of hypertensive patients as an opportunity for reducing inappropriate care. They developed a quality improvement project aimed at reducing the use of IV antihypertensive medications where warranted.
In the study, the authors stated: “The goal of the intervention was to have nurses assess for end-organ damage and alternate etiologies and include this information on their assessment provided to the physician, which would result in appropriate treatment of elevated blood pressure.”
This first-of-its-kind intervention was implemented on two inpatient medicine units at Mount Sinai, an urban, 1,134-bed tertiary medical center, from March 2017 to February 2018. The intervention included education, a treatment algorithm, monthly feedback and changes to the electronic medical record order sets. It targeted nurses, house staff, nurse practitioners and attending physicians on medical teaching and nonteaching services.
First, representatives from the nursing and cardiology departments developed a clinical algorithm to guide nurses and house staff in evaluating why a patient’s blood pressure might be elevated, including causes that might not require aggressive treatment. They also developed a table and flowchart outlining the oral medications used for hypertensive urgency, which affects the vast majority (98%) of hospitalized patients with high blood pressure.
Educational sessions were held at monthly nursing huddles, and the table and flowchart were added to an existing mobile app to provide clinicians with easy access. Rotating house staff received emails introducing them to the QI project and providing the treatment algorithm. Monthly feedback was given to nurses and providers who ordered IV treatment without appropriate indications, and EMR alerts were placed on orders for two popular IV antihypertensive medications to remind clinicians to assess for appropriate symptoms.
In comparing seven-month pre-intervention and 12-month post-intervention data, the project team found that inappropriate orders decreased by 60 percent per 1,000 patient days, and adverse events associated with use of IV antihypertensive medications declined by 57 percent per 1,000 patient days. The results were based on 260 one-time orders on the two medical units.
“By performing an interdisciplinary intervention, we addressed the knowledge deficit of both nurses and physicians, improved the triage of elevated blood pressure, and likely decreased the number of pages to providers,” the authors wrote.