Quality improvement plan for BP treatment

Introduction

The question of introducing a quality improvement plan to treat hypertension in urgent care is crucial, given the current state of hypertension control in the United States. Mills et al. (2020) argue that hypertension is mostly preventable and controllable. However, progress in improving hypertension control has stalled over the last decade, and the ongoing COVID-19 pandemic has disrupted preventive care and presented barriers to hypertension control. Kirkland et al. (2018) emphasize that without improvements in healthy lifestyle behaviors and healthcare delivery, the decade-long improvements in cardiovascular health will erode. Furthermore, Bhutani et al. (2021) and Czeisler et al. (2020) note that the pandemic has led to worsening mental health and unhealthy coping mechanisms such as unhealthy eating and decreased physical activity, further exacerbating hypertension control.

Addressing the disparities in hypertension awareness, treatment, and control among racial and ethnic populations in the United States is critical. The Centers for Disease Control and Prevention [CDC] (2021) argue that this issue must be addressed, given ample evidence for the prevention and control of hypertension. Additionally, Himmelfarb et al. (2016) highlight the role of nurses in preventing and managing hypertension. Hence, introducing a quality improvement plan that accounts for racial and ethnic disparities and promotes the involvement of nurses could significantly improve hypertension control in urgent care settings.

The 2020 Surgeon General’s Call to Action to Control Hypertension identified three broad goals in response to worsening hypertension control. The goals are to (1) make hypertension a national priority, (2) ensure that places where people live, work, and play support hypertension control, and (3) optimize patient care for hypertension control (U.S. Department of Health and Human Services, 2020a; Judith et al., 2022). Thus, introducing a quality improvement plan should align with these goals and ensure that it accounts for the broader context of hypertension control.

Thesis

Regarding hypertensive urgencies, there is a lack of Canadian data on whether referrals to the emergency department (E.D.) regarding hypertension are appropriate. Recent guidelines advise against referring patients with hypertensive urgencies to the E.D. for treatment. Referrals to the Montfort Hospital E.D. due to hypertension were analyzed and assessed if they met the criteria for hypertensive emergencies (Richard et al., 2021). Therefore, any quality improvement plan for treating hypertension in urgent care must account for the appropriate management of hypertensive urgencies to avoid unnecessary referrals to the E.D.

Despite recommendations to optimize oral antihypertensive regimens with appropriate follow-up care for hypertensive urgencies, many patients are referred to overcrowded emergency rooms for unrequired acute care. There is currently a lack of specific data from Canadian institutions regarding the incidence of true hypertensive emergencies (Richard et al., 2021). As such, any quality improvement plan aimed at treating hypertension in urgent care settings should ensure that patients with hypertensive urgencies receive the appropriate care to avoid unnecessary referrals to the E.D. and improve hypertension control.

Background

Hypertension is a major global health concern, and effective treatment is essential to prevent serious complications. The American College of Cardiology (ACC), together with the American Heart Association (AHA), published new guidelines in 2017 recommending intensive blood pressure (B.P.) control to reduce the risk of cardiovascular events and mortality. However, there is some uncertainty regarding the optimal B.P. targets. Recent trials, such as SPRINT and ACCORD, yielded mixed results. More intensive B.P. control significantly reduced cardiovascular events and mortality in some studies but not in others. These findings highlight the need for effective quality improvement plans to improve hypertension treatment in urgent care settings (Xu, Zhang, & Kwak, 2019; Sadeghi et al., 2020).

To effectively manage hypertension, clinicians must know the ACC/AHA guidelines and classify patients according to their B.P. level. Lifestyle modifications and BP-lowering medications are recommended for patients with stage 1 or 2 hypertension, and close follow-up is necessary to monitor B.P. However, achieving B.P. control can be challenging due to multiple barriers, including patient adherence to medication, accurate B.P. measurement, and a lack of appropriate guideline-based therapy. To address these barriers, interventions such as non-pharmacological therapy, medication reconciliation, and education for physicians, nursing staff, and patients can be effective (Burnier & Egan, 2019; Mondoux, 2020).

Discussion

In addition to these interventions, specific strategies can address patient-related barriers to hypertension treatment, such as medication non-adherence and missed appointments. Prescription of generic medications and combination therapy can improve medication adherence, and providing a 90-day supply can overcome transportation barriers to the pharmacy. Home B.P. monitoring and increased clinic visits can improve patient engagement and communication, leading to better medication adherence and education counseling. Older patients and those with fewer medications may have higher adherence, and phone coaching can effectively improve medication adherence, home B.P. monitoring, and lifestyle modifications (Uchmanowicz et al., 2019; Sadeghi et al., 2020).

When managing hypertensive urgencies, referrals to the emergency department may not always be necessary. Canadian data is lacking in this area, and assessing whether referrals meet the criteria for hypertensive emergencies is important. This highlights the need to effectively manage hypertensive urgencies in urgent care settings to prevent unnecessary referrals and ensure appropriate treatment (Richard et al., 2021). Implementing a quality improvement plan that addresses the multiple barriers to hypertension treatment can be effective in urgent care settings. This plan should include strategies to improve patient adherence to medication and appointments, medication reconciliation, physician education, and appropriate management of hypertensive urgencies. By following ACC/AHA guidelines and utilizing these interventions, clinicians can provide better care for patients with hypertension and prevent serious complications.

Plan for Q.I. Project

To introduce a quality improvement plan for hypertension treatment in urgent care, we will conduct a retrospective cohort study from April 1 to April 31, 2023, using electronic health record data from 10 Cleveland Clinic Hospitals. This study is approved by the institutional review board of Cleveland Clinic, and we will seek a consent waiver because the study poses minimal risk to participants. The study will follow the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline (Rastogi et al., 2021).

Cohort

In our cohort, we will include patients older than 18 years admitted to a medicine service, excluding those with a cardiovascular diagnosis or admission within the past 30 days for acute coronary syndrome or cerebrovascular events, pregnant patients, and those with a length of stay less than two or greater than 14 days. For patients with multiple admissions, we will randomly select a single admission. Patients without outpatient medication data will also be excluded (Rastogi et al., 2021).

Measures

We will collect all systolic blood pressures (SBPs), diastolic blood pressures (DBPs), and heart rates, excluding measurements from the intensive care unit. Hypertension will be defined by an SBP measurement of at least 140 mm Hg.

Adjusters

We will collect patient characteristics associated with treatment, including demographic details (age, sex, and race/ethnicity) obtained from medical records, comorbidities (cardiovascular disease, diabetes, and chronic kidney disease), and B.P. characteristics, including the maximal SBP and DBP, time from admission in hours, hospital shift during which the B.P. was measured, change from prior SBP, and proportion of the previous two measures that were elevated. Race/ethnicity will be included in the analysis, as hypertension disparities and antihypertensive intensification disparities are well established. Race/ethnicity options will be defined by the health system (Rastogi et al., 2021).

Medications

We will collect all medications administered before, during, and after admission to classify medications. We will use the 2017 Guideline for High Blood Pressure in Adults to classify medications, excluding spironolactone and loop diuretics. The antihypertensive drug classes we will include are angiotensin-converting enzyme inhibitors, calcium channel blockers, angiotensin receptor blockers (subtype 2), ?-blockers, direct-acting vasodilators, central ?2-receptor agonists, potassium-sparing diuretics, thiazide diuretics, and peripheral ?1-receptor blockers. We will categorize the route of administration as intravenous (IV), oral, or other (e.g., transdermal or intramuscular) (Rastogi et al., 2021).

Expected Outcomes

In introducing a quality improvement plan to treat hypertension in Urgent Care, the initial step will be the acute treatment of elevated blood pressure. This will involve administering an intravenous antihypertensive or a new class of oral antihypertensive. Patients who receive medication before admission will be considered to continue their outpatient therapy rather than treat specific blood pressure. The treated measure will be based on the blood pressure reading immediately before treatment. At the patient level, a single measurement will be identified as the index blood pressure for determining subsequent outcomes. The highest treated blood pressure will be the index blood pressure, while for untreated patients, the highest blood pressure during admission will be the index blood pressure. Index blood pressures will be matched using patient and blood pressure characteristics (Anderson, Jing, Auerbach, et al., 2019; Rastogi et al., 2021).

The second step in the quality improvement plan is to monitor inpatient events that show end-organ damage, such as acute kidney injury, myocardial injury, stroke, and a composite of all three. These events will be considered only if they occur after the index blood pressure reading. Strokes will be identified through the discharge diagnosis and confirmed through chart review. The AKI Network definition will define acute kidney injury, where a serum creatinine increase of at least 0.3 mg/dL or 1.5 times the initial value. The myocardial injury will be based on elevated troponin levels of more than 0.029 ng/mL for troponin T and more than 0.045 ng/mL for troponin I (Breu & Axon, 2018; Pasik, Chiu, Yang, et al. 2019).

Finally, the third step in the quality improvement plan is to assess medication intensification at discharge. Medication intensification will be defined as prescribing an antihypertensive class at discharge that was not present before preadmission. It will be examined whether intensification at discharge was associated with short-term adverse events such as myocardial infarction and stroke within 30 days. The study will also assess blood pressure control in the year after discharge (Jacobs, Najafi, Fang, et al., 2019; Rastogi et al., 2021). Overall, the quality improvement plan aims to enhance hypertension treatment in Urgent Care through acute treatment of elevated blood pressure, monitoring inpatient events that show end-organ damage, and assessing medication intensification at discharge.

Evaluate the Q.I. Project

A clear understanding of hypertensive emergencies and the appropriate use of intravenous (IV) antihypertensive therapy is required when evaluating a quality improvement plan to treat hypertension in urgent care. Hypertensive emergencies are commonly associated with patients presenting with a systolic blood pressure (SBP) of >220 mm Hg and/or diastolic blood pressure (DBP) of >120 mm Hg. However, even with lower thresholds, hypertensive emergencies can occur with rapid elevations from low-to-normal baseline B.P. Furthermore, patients with concomitant acute organ injury, for which immediate B.P. lowering can modify the injury, require immediate B.P. reduction. Patients presenting with new or worsening end-organ injury require IV antihypertensive therapy to achieve immediate B.P. reduction. Nonetheless, patients who require IV antihypertensive therapy are limited to a small proportion with strict oral medication restrictions and those who suddenly withdraw from beta-blockade or sympatholytic therapy. Despite this, most IV medications used to achieve immediate B.P. reduction in the emergency department are inappropriately administered to patients who do not have new or worsening end-organ injuries that can be modified by rapid treatment. (Miller et al, 2020). (Miller et al, 2020).

When treating hypertensive emergencies in urgent care, relying solely on symptoms to define such emergencies is not advisable for clinicians. Although specific symptoms such as acute dyspnea or chest pain may prompt immediate treatment, they do not define hypertensive emergencies. Hypertensive emergencies are confirmed by additional diagnostic tests that confirm acute organ injury. For the majority of patients, presenting clinical features are too nonspecific to prompt immediate IV antihypertensive therapy without confirmatory testing. Rapid B.P. lowering may be indicated in acute ischemic stroke patients when B.P. exceeds 185/110 mm Hg and thrombolytic or endovascular treatment is planned. However, acute lowering may worsen ischemia, as the ischemic penumbra lacks auto-control of blood flow and relies on systemic perfusion pressure. Therefore, in urgent care, a quality improvement plan to treat hypertension should prioritize confirming acute organ injury before initiating IV antihypertensive therapy and avoid unnecessary lowering of B.P. in patients without new or worsening end-organ injury. (Miller et al, 2020; Powers, Rabinstein, Ackerson, 2018). Therefore, in urgent care, a quality improvement plan to treat hypertension should prioritize confirming acute organ injury before initiating IV antihypertensive therapy and avoid unnecessary lowering of B.P. in patients without new or worsening end-organ injury.

Moreover, it is essential to determine the specific tests indicated for patients suspected of hypertensive emergencies. These tests include a basic metabolic profile, complete blood count, urinalysis, electrocardiogram, and chest x-ray. Further evaluation of patients with markedly elevated blood pressure (B.P.) should be symptom-based and aligned with each associated condition’s differential diagnosis. In patients with altered mental status and B.P.>220/120 mm Hg, brain imaging by computed tomography is required to assess for intracerebral hemorrhage or hypertensive encephalopathy. Magnetic resonance imaging may be necessary if neither hemorrhage on computed tomography nor alternative reasons for altered mental status are present. Similarly, patients with concurrent shortness of breath or chest pain should obtain biomarkers of cardiac injury (troponin) and stress (natriuretic peptides), with the addition of computed tomography angiography of the thorax and abdomen when an acute aortic syndrome is suspected. Figure 1 demonstrates a general approach to patients with markedly elevated B.P. (Miller, Suchdev, and Jayaprakas, 2018).

The current treatment for hypertensive emergencies involves rapid B.P. reduction to reverse new or worsening end-organ injury and prevent further damage. In line with the 2017 guidelines by the American College of Cardiology and the American Heart Association Task Force, the recommendation is to reduce the mean arterial pressure (MAP) by 25% within the first hour of treatment. The right baseline shift in the cerebral autoregulation curve with chronic hypertension is understood to reset approximately 25% above the average MAP. However, with acute B.P. elevation, an individual with a hypertensive emergency may withstand greater B.P. drops as they are on the ascendant portion of the autoregulation curve. Carefully titrated intravenous (IV) antihypertensive medications are the preferred initial treatment approach to limit the risk of cerebral hypoperfusion that may be caused by reducing B.P. too quickly. Over the next 2–6 hours, further B.P. reduction should occur with the goal of a systolic B.P. of 160 mm Hg and diastolic B.P. of 100–110 mm Hg. Following the emergency department (E.D.) management, inpatient B.P. reduction aims to reach a normal range gradually within 24–48 hours. For individual disease processes, additional guidelines exist to tailor B.P. management, and the optimal B.P. goal for immediate intervention may be greater than 25% of MAP. The most common medications indicated for treatment are nicardipine, labetalol, clevidipine, and esmolol. While nitroprusside was a mainstay of treatment for decades, antihypertensive medications such as nicardipine and clevidipine demonstrate similar efficacy, are easy to titrate, and have no concern for possible cyanide toxicity. The existing literature does not provide sufficient evidence to show that any specific IV antihypertensive agent is superior to another, though the dihydropyridine agents (nicardipine and clevidipine) and labetalol, are preferred agents in the setting of neurological hypertensive emergencies (Miller et al., 2020).