Diagnosis, Treatment, and Referral of Hypertension or Prehypertension in an Emergency Department After an Educational Program: Preliminary Results

Authors


  • Presented at the Annual Meeting of the American Heart Association, Chicago, Illinois on November 17, 2010.

Wilbert S. Aronow, MD, Division of Cardiology, New York Medical College, Macy Pavilion, Room 138, Valhalla, NY 10595
E-mail: wsaronow@aol.com

Abstract

The authors prospectively audited 602 randomly selected charts of patients seen in an academic emergency department (ED) for prevalence of hypertension and its management after an educational program (EP) because of results found in auditing 500 charts before the EP. Blood pressure was not measured in 11 of 500 patients (2.2%) before the EP and in 1 of 602 patients (0.2%) after the EP (P<.005). Hypertension was treated in the ED in 14 of 187 patients (8%) before the EP and in 29 of 282 patients (10%) after the EP (P=not significant). Of 187 patients with hypertension before the EP, 99 (53%) were referred to a physician or clinic for follow-up of hypertension, and 281 of 282 patients (99.6%) with hypertension were referred to a physician or clinic for follow-up of hypertension after the EP (P<.001). These data show that an EP administered to the staff of an academic ED significantly increased measurement of blood pressure in the ED, significantly increased obtaining a history of hypertension and of its treatment in ED patients, and significantly increased referral of patients with hypertension to a physician or clinic for follow-up of hypertension. J Clin Hypertens (Greenwich). 2011;13:413–415. ©2011 Wiley Periodicals, Inc.

Hypertension is a major risk factor for coronary events,1–6 stroke,1,2,6–9 congestive heart failure,1,2,10,11 and peripheral arterial disease.12–16 Emergency department (ED) physicians have done a poor job in recognizing, treating, and referring patients with hypertension for follow-up care.17–21 In addition, many patients being seen for medical care in the ED do not have a primary care physician or access to primary care.

In March 2006, the American College of Emergency Physicians (ACEP) Clinical Policies Subcommittee recommended that patients with hypertension should be referred for follow-up of hypertension and treatment.22 We previously reported in a prospective study from the ED of a university medical center that 11 of 500 patients (2.2%) seen in the ED did not have their blood pressure (BP) measured.23 Of the 489 patients who had their BP measured, 187 patients (38%) had hypertension diagnosed. Of the 187 patients with hypertension, 14 (8%) were treated for hypertension in the ED and 99 (53%) were referred to a physician or clinic for follow-up of their hypertension.23

These data were discussed with the medical director of the ED and with the medical staff of the ED. An educational program about the importance of diagnosing hypertension, treating it, and referring patients with hypertension for follow-up care was then given to the medical staff of the ED and a grand rounds on this topic given to the medical staff. The medical staff was also taught to obtain follow-up BPs in the ED if the BP was elevated.

After this educational program, a prospective study was then repeated during a 7-month period in 602 patients seen in the ED to determine whether the educational program had an effect on the prevalence of measuring BP, the prevalence of treatment of hypertension in the ED, and the prevalence of referring patients with hypertension for follow-up care of their hypertension.

Methods

An educational program was administered to the medical staff of the ED about the importance of diagnosing hypertension, treating it, and referring patients with hypertension for follow-up care of their hypertension. After administration of this educational program for 6 months, we audited in a prospective study 602 randomly selected charts of patients seen during a 7-month period (November 2009 through May 2010) in the ED of Westchester Medical Center/New York Medical College for the prevalence of hypertension and how it was managed. There were no inclusion or exclusion criteria for selection of these patients. There was no control population involved. The age, sex, race, and BP taken in the ED of each patient were recorded. Hypertension was diagnosed if systolic BP was ≥140 mm Hg or diastolic BP was ≥90 mm Hg. The last BP value recorded in the chart prior to treatment was used. Since this was a study of patients with uncontrolled hypertension, patients with normal BPs while taking medication were not classified as having hypertension.

In the patients with hypertension, a history of hypertension, current therapy for hypertension, atherosclerotic vascular disease, diabetes mellitus, congestive heart failure, and chronic kidney disease were recorded. Whether the hypertension was treated in the ED and whether the patient was referred to a physician or clinic for follow-up of their hypertension were also recorded. The physicians and nurses in the ED were aware that this study was being performed.

Student t tests were used to analyze continuous variables. Chi-square tests were used to analyze dichotomous variables.

This study was approved by the New York Medical College institutional review board and by the institutional review board of Westchester Medical Center.

Results

The 602 patients included 311 men and 291 women, with a mean age of 53±14 years. Of the 602 patients, 313 (52%) were white and 289 (48%) were nonwhite. The BP was not measured in 11 of 500 patients (2.2%) before the educational program and in 1 of 602 patients (0.2%) after the educational program (P<.005).

Of the 601 patients in whom BP was measured, 282 (47%) had hypertension. Systolic and diastolic hypertension were present in 166 of 601 patients (28%), isolated systolic hypertension in 114 of 601 patients (19%), and isolated diastolic hypertension in 2 of 601 patients (<1%). A history of hypertension was obtained in 103 of 187 patients (55%) with hypertension before the educational program and in 209 of 282 patients (74%) with hypertension after the educational program (P<.001). A history of treatment for hypertension was obtained in 73 of 187 patients (39%) with hypertension before the educational program and in 189 of 282 patients (67%) with hypertension after the educational program (P<.001).

Of 282 patients with hypertension, 62 (22%) had a history of coronary artery disease, 85 (30%) had a history of diabetes mellitus, 27 (10%) had a history of stroke or transient ischemic attack, 22 (8%) had a history of peripheral arterial disease, 23 (8%) had a history of chronic renal disease, and 25 (9%) had a history of congestive heart failure. Table I shows the prevalence of different levels of systolic and diastolic hypertension in the 601 patients in whom BP was measured in the ED. Table II shows the baseline characteristics of the 282 patients with hypertension.

Table I.   Prevalence of Different Levels of Systolic and Diastolic Hypertension in 601 Patients in Whom Blood Pressure (BP) Was Measured in the Emergency Department
BP, mm HgNo (%)
Systolic BP ≥2006 (1)
Systolic BP ≥19013 (2)
Systolic BP ≥18028 (5)
Systolic BP ≥17041 (7)
Systolic BP ≥160103 (17)
Systolic BP ≥150156 (26)
Systolic BP ≥140280 (47)
Diastolic BP ≥1204 (1)
Diastolic BP ≥11020 (3)
Diastolic BP ≥10066 (11)
Diastolic BP ≥90168 (28)
Table II.   Baseline Characteristics of 282 Patients With Hypertension Diagnosed in the Emergency Department
VariableNo. (%)
Men146 (52)
Women136 (48)
Age, y 55±14
Whites135 (48)
Nonwhites147 (52)
History of hypertension209 (74)
Treatment for hypertension189 (67)
Coronary artery disease62 (22)
Diabetes mellitus85 (30)
Stroke or transient ischemic attack27 (10)
Peripheral arterial disease22 (8)
Chronic renal disease23 (8)
History of heart failure25 (9)

Hypertension was treated in the ED in 14 of 187 patients (8%) before the educational program and in 29 of 282 patients (10%) after the educational program (P=not significant). Of the 187 patients with hypertension before the educational program, 99 (53%) were referred to a physician or clinic for follow-up of their hypertension, and 281 of 282 patients (99.6%) with hypertension were referred to a physician or clinic for follow-up of their hypertension after the educational program (P<.001).

Discussion

Hypertension should be treated to decrease cardiovascular events and mortality.1,24–26 ED physicians have done a poor job in recognizing, treating, and referring patients with hypertension for follow-up care.17–21 In an ED of a tertiary care teaching hospital, 1574 patients had hypertension.17 Of these 1574 patients, a discharge diagnosis of hypertension was made in 93 patients (6%), antihypertensive treatment was given in the ED to 38 patients (2%), discharge instructions for follow-up of BP were given to 82 patients (5%), and a prescription for antihypertensive drugs was given to 33 patients (2%).17

Of 137 patients seen in a university ED who needed referral for hypertension management, 5 (4%) were referred.18 Of 37 patients with hypertension seen in the ED of an academic medical center, 27 (73%) did not have their BP rechecked and were not referred for follow-up of their hypertension.19 Of 269 patients with a BP ≥180/110 mm Hg seen in the ED of an academic medical center, 56 patients (21%) received antihypertensive treatment.20

A survey of 306 physicians and nurses in 4 EDs in academic medical centers found that both physicians and nurses considered hypertension a low priority.21 On the basis of the available data, the ACEP Clinical Policies Subcommitttee recommended in March 2006 that patients with hypertension should be referred for follow-up of hypertension and treatment.22

The present prospective study showed that BP was not measured in patients seen in the ED in 2.2% of patients before the educational program vs 0.2% of patients after the educational program (P<.005). A history of hypertension was obtained in 103 of 187 patients (55%) with hypertension before the educational program and in 209 of 282 patients (74%) with hypertension after the educational program (P<.001). A history of treating hypertension was obtained in 73 of 187 patients (39%) with hypertension before the educational program and in 189 of 282 patients (67%) with hypertension after the educational program (P<.001). Hypertension was treated in the ED in 14 of 187 patients (8%) before the educational program and in 29 of 282 patients (10%) after the educational program (P=not significant). Of 187 patients with hypertension before the educational program, 99 (53%) were referred to a physician or clinic for follow-up of hypertension, and 281 of 282 patients (99.6%) with hypertension were referred to a physician or clinic for follow-up of hypertension after the educational program (P<.001).

Some of the patients with hypertension may have had acutely elevated BPs due to their presenting complaint. These patients may have prehypertension and need follow-up care.

The physician director of our ED is interested in improving the quality of medical care provided in the ED. He will use their current electronic medical system and enhance this system with an Allscripts program (Allscripts Healthcare Solutions, Inc, Chicago, IL) in which abnormal BP values will be addressed.

Conclusions

An educational program with the support of the medical director of the ED is valuable in the identification of hypertension with several BP measurements made in the ED, treatment of hypertension in the ED if indicated, and referral of patients to a physician or clinic for follow-up of their hypertension.

Acknowledgments

Disclosures:  None of the authors have any conflict of interest pertaining to this paper.

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