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
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. 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.
To our knowledge, this is the first intervention addressing the inpatient overuse of IV antihypertensive medications for the treatment of asymptomatic hypertension. Additionally, this study bolsters prior evidence that the use of IV antihypertensives in asymptomatic patients leads to a large number of adverse events.7 A third of patients in the preintervention period had documented alternate etiologies of their blood pressure elevation, highlighting the need to assess and potentially treat these causes prior to treating blood pressure itself.
Reducing unnecessary treatment of asymptomatic blood pressure elevation is challenging. Evidence shows that both clinicians and patients overestimate the benefits and underestimate the harms of medical interventions.13,14 This unfortunately leads to unjustified enthusiasm for medical treatments, which can worsen outcomes.15 Additionally, there may be a lack of knowledge of the guidelines, as well as the amount of time required in the full assessment of hypertensive urgency, that creates a culture of “treating the number.”
Changing physician behavior is difficult.16 However, active forms of continuing education and multifaceted interventions, such as ours, are most effective.17 Our message focused on patient safety and harm reduction, addressed clinicians’ safety concerns, and included stories of real cases where this overuse led to adverse events—all of which are encouraged in order to facilitate clinician engagement.18
There were limitations to this study. Only blood pressure elevations associated with an IV antihypertensive order and not all blood pressure elevations meeting the criteria for hypertensive urgency in general were examined. Additionally, our documentation of symptoms of hypertensive emergency and alternate etiologies was based only on documentation in the medical record. Ideally, we would have liked to conduct an interrupted time series analysis to assess the effect of the intervention over time; however, there were not enough orders of IV antihypertensives to perform such an analysis.
CONCLUSION
Treatment of asymptomatic blood pressure with IV antihypertensive medications can lead to patient harm. To reduce inappropriate treatment, our Student High Value Care team set out to challenge this common practice. Our interdisciplinary intervention successfully reduced unnecessary IV antihypertensive treatment. This may serve as a model for other institutions.
Disclosures
There are no relevant conflicts of interest to disclose for any authors.
