Assess Before Rx: Reducing the Overtreatment of Asymptomatic Blood Pressure Elevation in the Inpatient Setting
BACKGROUND: Asymptomatic blood pressure elevation is common in the inpatient setting. National guidelines recommend treating with oral agents to slowly decrease blood pressure; however, many clinicians use intravenous antihypertensive medications, which can lead to unpredictable changes in blood pressure.
OBJECTIVE: To decrease the number of inappropriate orders (without symptoms of hypertensive emergency or order for NPO) of intravenous antihypertensives and adverse events associated with intravenous orders.
DESIGN: Quasi-experimental study with multidisciplinary intervention. PARTICIPANTS: Inpatients with a one-time order for an intravenous antihypertensive agent from January 2016 to February 2018.
MAIN MEASURES: The main outcomes were the total numbers of orders and inappropriate orders, adverse events, and alternate etiologies per 1,000 patient-days. As a balancing measure, patients were monitored for adverse events when blood pressure was elevated and not treated.
KEY RESULTS: There were a total of 260 one-time orders of intravenous antihypertensives on two medical units. Inappropriate orders decreased from 8.3 to 3.3 per 1,000 patient days (P = .0099). Adverse events associated with intravenous antihypertensives decreased from 3.7 to 0.8 per 1,000 patient days (P = .0072).
CONCLUSION: This initiative demonstrated a significant reduction in inappropriate use of IV antihypertensives and an associated reduction in adverse events.
© 2019 Society of Hospital Medicine
With the presence of hypertension in 25% of patients admitted to the hospital,1 its proper management is imperative. A hypertensive crisis is a severe elevation of blood pressure, defined as systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg. It is further classified as either a hypertensive emergency which includes the presence of end-organ damage,2 or hypertensive urgency, defined as asymptomatic blood pressure elevation.3 Although hypertensive emergencies account for only 1%-2% of patients with hypertension,4 they are associated with a high one-year mortality rate (>79%).5 Hypertensive emergency requires immediate reduction of blood pressure with IV antihypertensive drugs to limit organ damage. In contrast, as per national guidelines, inpatient management of hypertensive urgency requires gradual reductions of blood pressure over hours to days using oral antihypertensives.2 It is also recommended that alternative etiologies, such as anxiety or pain, be considered before treatment is initiated.1
Clinicians often inappropriately treat asymptomatic hypertension in the inpatient setting,6,7 using intravenous (IV) antihypertensive medications despite evidence showing potential harm.5,8 This can lead to unpredictable reductions in blood pressure.7,9 A recent retrospective analysis demonstrated that 32.6% of patients had a blood pressure reduction greater than 25% after the use of an IV antihypertensive.7 Reductions greater than 25% lead to shifts in autoregulation, which may result in patient harm, such as hypotension, decreased renal perfusion, and stroke.9 IV medications are also more expensive than oral agents, due to the additional cost of administration.
Although overtreatment of asymptomatic hypertension with IV antihypertensive medications is common,7 initiatives to address this in inpatient settings are lacking in the literature. The aim of this quality improvement initiative was to reduce unnecessary IV antihypertensive treatment for hypertensive urgency in the inpatient setting.
METHODS
Setting
An interdisciplinary quality improvement intervention was initiated on two inpatient medicine units at an urban, 1,134-bed tertiary medical center affiliated with the Icahn School of Medicine at Mount Sinai. Members of the Mount Sinai High Value Care Committee and the Student High Value Care Initiative10 developed this project. The intervention was implemented in stages from March 2017 to February 2018. It targeted nurses, housestaff, nurse practitioners, and attendings on general medical teaching and nonteaching services. The components of the intervention included education, a treatment algorithm, audit and feedback, and electronic medical record (EMR) change. This project was submitted to the Quality Committee in the Department of Medicine and determined to be a quality improvement project rather than research and thus, an IRB submission was not required.
