Reducing Unnecessary Treatment of Asymptomatic Elevated Blood Pressure with Intravenous Medications on the General Internal Medicine Wards: A Quality Improvement Initiative
BACKGROUND: Asymptomatic elevated blood pressure (BP) is common in the hospital. There is no evidence supporting the use of intravenous (IV) antihypertensives in this setting.
OBJECTIVE: To determine the prevalence and effects of treating asymptomatic elevated BP with IV antihypertensives and to investigate the efficacy of a quality improvement (QI) initiative aimed at reducing utilization of these medications.
DESIGN: Retrospective cohort study.
SETTING: Urban academic hospital. PATIENTS: Patients admitted to the general medicine service, including the intensive care unit (ICU), with ≥1 episode of asymptomatic elevated BP (>160/90 mm Hg) during hospitalization.
INTERVENTION: A two-tiered, QI initiative.
MEASUREMENTS: The primary outcome was the monthly proportion of patients with asymptomatic elevated BP treated with IV labetalol or hydralazine. We also analyzed median BP and rates of balancing outcomes (ICU transfers, rapid responses, cardiopulmonary arrests).
RESULTS: We identified 2,306 patients with ≥1 episode of asymptomatic elevated BP during the 10-month preintervention period, of which 251 (11%) received IV antihypertensives. In the four-month postintervention period, 70 of 934 (7%) were treated. The odds of being treated were 38% lower in the postintervention period after adjustment for baseline characteristics, including length of stay and illness severity (OR = 0.62; 95% CI 0.47-0.83; P = .001). Median SBP was similar between pre- and postintervention (167 vs 168 mm Hg; P = .78), as were the adjusted proportions of balancing outcomes.
CONCLUSIONS: Hospitalized patients with asymptomatic elevated BP are commonly treated with IV antihypertensives, despite the lack of evidence. A QI initiative was successful at reducing utilization of these medications.
© 2019 Society of Hospital Medicine
Elevated blood pressure (BP) is common among hospitalized adults, with prevalence estimates between 50% and 70%.1 Many factors can cause or exacerbate BP elevations in the setting of acute illness, such as pain, anxiety, medication withdrawal, and volume status, among others.2 While there are clear evidence-based recommendations for treating hypertension (HTN) in the ambulatory setting,3 guidelines for the management of elevated BP in the hospital are lacking.4,5
Hypertensive crises are generally recognized as warranting rapid reduction in BP;6-8 however, these represent the minority of cases.9,10 Far more common in the hospital are patients with asymptomatic elevated BP, a population for which there is no high-quality evidence and no guidelines supporting the use of intravenous (IV) antihypertensives.11,12 Treatment with such medications has been associated with highly variable clinical responses13-15 and may result in adverse events, such as hypotension.10
To date, only a small number of studies have investigated the treatment of asymptomatic elevated BP among hospitalized adults.10,13-15 These have suggested that IV antihypertensives are utilized frequently in this setting, often for only modestly elevated BPs; however, the studies have tended to be small, not racially diverse, and limited to noncritically ill patients. Furthermore, while it is generally accepted that reducing the use of IV antihypertensives among asymptomatic patients would have no adverse impact, to our knowledge there have been no published studies which have instituted such an initiative while measuring balancing outcomes.
The purpose of this study was to further the existing literature by defining the prevalence and effects of IV antihypertensive medication utilization among a medically complex, multiracial population of asymptomatic medical inpatients using a large electronic dataset and to evaluate the impact of a division-wide, two-tiered quality improvement (QI) initiative on the rates of IV antihypertensive utilization and patient outcomes.
METHODS
Setting
The study was conducted at the University of California, San Francisco (UCSF), an 800-bed tertiary care, academic medical center. It was approved by the UCSF Institutional Review Board. General medicine patients at UCSF are distributed between teaching and direct-care (hospitalist) services. The intensive care unit (ICU) is “open,” meaning the medicine service acts as the primary team for all nonsurgical ICU patients. This study included all adult general medicine patients admitted to UCSF Medical Center between January 1, 2017 and March 1, 2018, including those in the ICU.
Study Population and Data Collection
The UCSF Medical Center uses the electronic health record (EHR) Epic (Epic 2017, Epic Systems Corporation, Verona, Wisconsin) for all clinical care. We obtained computerized EHR data from Clarity, the relational database that stores Epic’s inpatient data in thousands of tables, including orders, medications, laboratory and radiology results, vital signs, patient demographics, and notes. We identified all adult patients hospitalized on the general medicine service with ≥1 episode of elevated BP (>160/90 mm Hg) at any point during their hospitalization who were not on a vasopressor medication at the time of the vital sign recording.
