Institutional Pathways to Improve Care of Patients with Elevated Blood Pressure in the Emergency Department.

Abstract

Hypertension (HTN) is the most prevalent cardiovascular disease and poses a major population level risk to long-term health outcomes. Despite this critical importance, and the widespread availability of effective and affordable medications, blood pressure (BP) remains uncontrolled in up to 50% of the diagnosed patients. This problem is exacerbated in communities with limited access to primary care, who often utilize hospital emergency departments (EDs) as their primary healthcare resource. Despite the ubiquity of patients presenting to EDs with severely elevated BP, a unified, evidence-based approach is not yet widely implemented, and both under- and overtreatment are common. The purpose of this review is to describe an approach towards institutional policy regarding asymptomatic HTN, in which we will translate the accepted principles of appropriate outpatient BP management to ED and inpatient settings. Results from the recent SPRINT trial, and the subsequent publication of the American Heart Association updated guidelines for the treatment of HTN, significantly lower both the diagnostic threshold and the treatment goals for hypertensive patients. This change will drastically increase the proportion of patients presenting to EDs with newly diagnosed and uncontrolled HTN. Several recent studies emphasize the safety in outpatient management of patients with severely elevated BP in the absence of acute end-organ damage and, conversely, the long- and intermediate-term risk associated with these patients. System-based approaches, particularly those led by non-physicians, have shown the greatest promise in reducing population level uncontrolled HTN. Evidence-based approaches, such as those described in emergency medicine and cardiology society guidelines, can guide appropriate management of ED and inpatient BP elevations. Translating these patient oriented guidelines into institutional policy, and maintaining provider adherence, is a challenge across healthcare institutions. We present here several examples of successful policies developed and implemented by the authors. While brief inpatient and ED encounters cannot replace long-term outpatient care, they have the potential to serve as a crucial inlet to health care and an opportunity to optimize care.