Quality Improvement Plan for Hypertension in Urgent Care

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 additional 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 poor dietary habits 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. Introducing a quality improvement plan that accounts for racial and ethnic disparities and promotes the involvement of nurses could therefore 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: (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). Any quality improvement plan should align with these goals and account for the broader context of hypertension control.

Regarding hypertensive urgencies, there is a lack of Canadian data on whether referrals to the emergency department (ED) for hypertension are appropriate. Recent guidelines advise against referring patients with hypertensive urgencies to the ED for treatment. Referrals to the Montfort Hospital ED due to hypertension were analyzed and assessed to determine whether 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 ED referrals.

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). Any quality improvement plan aimed at treating hypertension in urgent care settings should therefore ensure that patients with hypertensive urgencies receive appropriate care to avoid unnecessary ED referrals and improve hypertension control.

Background and Clinical Guidelines

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 (BP) control to reduce the risk of cardiovascular events and mortality. However, some uncertainty remains regarding optimal BP targets. Recent trials — such as SPRINT and ACCORD — yielded mixed results: more intensive BP 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 et al., 2019; Sadeghi et al., 2020).

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

Discussion of Barriers and Treatment Strategies

In addition to these interventions, specific strategies can address patient-related barriers to hypertension treatment, such as medication non-adherence and missed appointments. Prescribing generic medications and combination therapy can improve medication adherence, and providing a 90-day medication supply can overcome transportation barriers to the pharmacy. Home BP monitoring and increased clinic visits can improve patient engagement and communication, leading to better medication adherence and education counseling. Older patients and those taking fewer medications may demonstrate higher adherence, and phone coaching can effectively improve medication adherence, home BP 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.

Conclusion

Early detection and treatment of elevated blood pressure can improve health outcomes and decrease costs associated with heart disease, the leading cause of death in the United States. Study results may be consistent with other research supporting referrals for follow-up care before patients leave urgent care facilities. However, to ensure the success of the quality improvement plan, policies must be developed to ensure continuity of care between urgent care facilities and PCPs. In addition, healthcare systems that allow EMRs to be shared between urgent care facilities and PCPs should be developed. Further research should be conducted to establish best practice policies for treating hypertension in urgent care settings.

Evaluating the quality improvement plan to treat hypertension in urgent care requires a focus on patient-centered care, collaboration, and health information technology. Metrics such as the number of patients who received follow-up care, patient satisfaction, and cost savings should be used to assess the plan's success. Implementing policies that ensure continuity of care and developing healthcare systems that allow the exchange of EMRs between urgent care facilities and PCPs are crucial for the success of the quality improvement plan. Further research should be conducted to identify best practices for treating hypertension in urgent care settings and to address the barriers to follow-up care.

References

Anderson, T. S., Jing, B., Auerbach, A., et al. (2019). Clinical outcomes after intensifying antihypertensive medication regimens among older adults at hospital discharge. JAMA Internal Medicine, 179(11), 1528–1536.

Bhutani, S., vanDellen, M. R., & Cooper, J. A. (2021). Longitudinal weight gain and related risk behaviors during the COVID-19 pandemic in adults in the U.S. Nutrients, 13(2), 671.

Breu, A. C., & Axon, R. N. (2018). Acute treatment of hypertensive urgency. Journal of Hospital Medicine, 13(12), 860–862.

Bundy, J. D., Li, C., Stuchlik, P., et al. (2017). Systolic blood pressure reduction and risk of cardiovascular disease and mortality: A systematic review and network meta-analysis. JAMA Cardiology, 2, 775–781.

Burnier, M., & Egan, B. M. (2019). Adherence in hypertension. Circulation Research, 124, 1124–1140.

Centers for Disease Control and Prevention. (2021). Hypertension cascade: Hypertension prevalence, treatment, and control estimates among U.S. adults aged 18 years and older applying the criteria from the American College of Cardiology and American Heart Association's 2017 Hypertension Guideline — NHANES 2015–2018.

Czeisler, M. É., Lane, R. I., Petrosky, E., Wiley, J. F., Christensen, A., Njai, R., et al. (2020). Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. Morbidity and Mortality Weekly Report, 69(32), 1049–1057.

Hayes, B. (2017). Quality improvement report: Elevated blood pressure referrals in an urgent care setting to increase follow-up appointments with primary care providers. The Journal of Urgent Care Medicine.

Health Forum. (2020). AHA Hospital Statistics. American Hospital Association.

Himmelfarb, C. R., Commodore-Mensah, Y., & Hill, M. N. (2016). Expanding the role of nurses to improve hypertension care and control globally. Annals of Global Health, 82(2), 243–253.

Jacobs, Z. G., Najafi, N., Fang, M. C., et al. (2019). Reducing unnecessary treatment of asymptomatic elevated blood pressure with intravenous medications on the general internal medicine wards: A quality improvement initiative. Journal of Hospital Medicine, 14(3), 144–150.

Judith, A. H., Commodore-Mensah, Y., Tokieda, N., Smith, A. P., Gawlik, K. S., et al. (2022). Improving hypertension control and cardiovascular health: An urgent call to action for nursing. Worldviews on Evidence-Based Nursing, 19(1), 6–15.

Kirkland, E. B., Heincelman, M., Bishu, K. G., Schumann, S. O., Schreiner, A., Axon, R. N., et al. (2018). Trends in healthcare expenditures among U.S. adults with hypertension: National estimates, 2003–2014. Journal of the American Heart Association, 7(11), 2003–2014.

Miller, J. B., Suchdev, K., Jayaprakash, N., Hrabec, D., Sood, A., Sharma, S., & Levy, P. D. (2018). New developments in hypertensive encephalopathy. Current Hypertension Reports, 20, 13.

Miller, J., McNaughton, C., Joyce, K., Binz, S., & Levy, P. (2020). Hypertension management in emergency departments. American Journal of Hypertension, 33(10).

Mills, K. T., Stefanescu, A., & He, J. (2020). The global epidemiology of hypertension. Nature Reviews Nephrology, 16(4), 223–237.

Mondoux, S. (2020). Designing a QI project: A comparison of quality improvement and traditional research paradigms.

Pasik, S. D., Chiu, S., Yang, J., et al. (2019). Assess before Rx: Reducing the overtreatment of asymptomatic blood pressure elevation in the inpatient setting. Journal of Hospital Medicine, 14(3), 151–156.

Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., ... Tirschwell, D. L. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e46–e110.

Rastogi, R., Sheehan, M. M., Shaker, V., Kojima, L., & Rothberg, M. B. (2021). Treatment and outcomes of inpatient hypertension among adults with noncardiac admissions. JAMA Internal Medicine, 181(3), 345–352.

Richard, A. E., & Chomienne, M. H. (2021). Review of referrals sent to the emergency department for management of hypertension. Cardiology Research, 12(3), 156–160. https://doi.org/10.14740/cr1233

Sadeghi, C., Khan, H. A., Gudleski, G., Reynolds, J. L., & Bakhai, S. Y. (2020). Multifaceted strategies to improve blood pressure control in a primary care clinic: A quality improvement project. International Journal of Cardiology Hypertension, 7.

U.S. Department of Health and Human Services. (2020a). The Surgeon General's call to action to control hypertension.

Uchmanowicz, B., Jankowska, E. A., Uchmanowicz, I., & Morisky, D. E. (2019). Self-reported medication adherence measured with Morisky Medication Adherence Scales and its determinants in hypertensive patients aged 60 years and older: A systematic review and meta-analysis. Frontiers in Pharmacology, 10, 168. https://doi.org/10.3389/fphar.2019.00168

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E. Jr., Collins, K. J., Dennison Himmelfarb, C., ... Wright, J. T. Jr. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary. Circulation, 138, e426–e483.

Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison Himmelfarb, C., et al. (2018). 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. Hypertension, 71(6), e13–e115.

Xu, L., Zhang, W., Kwak, M., Zhang, L., Lee, P. C. W., & Jin, J. O. (2019). Protective effect of melatonin against polymicrobial sepsis is mediated by the anti-bacterial effect of neutrophils. Frontiers in Immunology, 10, 1371. https://doi.org/10.3389/fimmu.2019.01371