March 7th, 2019
When a patient in the hospital has elevated blood pressure, but no other symptoms related to a hypertensive emergency, what should be the course of action? While there are many guidelines for treating chronic high blood pressure in the outpatient (community) setting, there is less of a consensus on how to treat hospital patients for asymptomatic hypertension.
On the one hand, hypertensive emergency — when high blood pressure leads to organ damage — is rare. Most of the time, high blood pressure in the hospital is due to a patient being in pain or anxious (common feelings to have when you’re in a hospital). On the other hand, hypertensive emergency is also very dangerous, which may lead doctors to take extreme measures to lower a patient’s blood pressure, even when it’s unlikely these measures are warranted. Unfortunately, treating patients with IV antihypertensives inappropriately often leads to sudden, huge drops in blood pressure, which can cause adverse events like renal dysfunction, dizziness, or stroke.
Members of the Mount Sinai High Value Care Committee and the Student High Value Care Initiative at Mount Sinai hospital decided to do something about unnecessarily aggressive treatment of hypertension at their hospital. They created and piloted a novel intervention called “Assess Before Rx” to reduce unnecessary IV antihypertensives and related adverse events. The team designed treatment algorithms (flow charts) for nurses, internal medicine housestaff, and nurse practitioners to use as a guide when a patient presented with elevated blood pressure. They also held educational sessions about the program at monthly nursing huddles, gave monthly feedback to nursing teams, and had EMR advisory warnings placed on IV antihypertensives to remind clinicians to check for symptoms of hypertensive emergency before prescribing.
The results of the pilot, recently published in the Journal of Hospital Medicine, were impressive. In the period after the intervention, the rate of inappropriate IV hypertensive orders decreased by 60% (from 8.3 to 3.3 orders per 1000 patient-days) and the rate of adverse drug events decreased by 57% (from 4.4 to 1.9 events per 1000 patient-days). The intervention also confirms that these IV medications were often ordered without sufficient prior assessment; researchers found that more than half of patients that received inappropriate IVs already had a documented reason for why their blood pressure could have been high.
By evaluating patients’ symptoms and medications before giving them the “quick fix” of an IV medication, Mount Sinai hospital saved many patients from harmful hypotension events and reduced the financial cost from these adverse events by 59%. Hopefully this program of continuing education, EMR alerts, and clinician engagement will be just as successful at other institutions.