Hypertension Best Practice Session 2 Blood Pressure Measurement and Management This is the second session of our Hypertension Best Practice model of care.

Hypertension Best Practice Elements Blood pressure (BP) measurement: including two BP readings if first is high (≥140/90 mmHg) Timely follow-up: monthly visits until BP controlled Treatment algorithm: low-cost, once-daily meds Communication: building trusting relationships Outreach: using a registry Here is a reminder of the elements of the hypertension best practice model of care: (read slide) BP measurement: include 2 BP readings if 1st is high Timely follow up: monthly visits until BP controlled Treatment algorithm: low cost once daily meds Communication: building trusting relationships Outreach: using a registry In this session we are going to focus mainly on elements 1 and 3 although may touch on element 2. Getting a second BP readings if 1st is high Scheduling patients for monthly visits until their BP is controlled Following /prescribing a treatment algorithm that consist of low cost once daily meds

A Model for Quality Improvement What are we trying to accomplish? (AIM) How will we know that a change is an improvement? (MEASURE) What change can we make that will result in improvement? (CHANGE OPPORTUNITIES) Before we start working on quality improvement, let’s review the model for quality improvement. You may want to explain the model for quality as follow: AIM- We need to state what we want to improve on and the reason we want to improve it. We need to know what our baseline data (rate) is and when was the baseline data gathered. We need to state what our target goal of improvement is and the time period we want to see improvement. We need to state what actions we will need to implement to bring about the improvement. We need to clearly define what we are trying to improve. For Example: “We want to increase the percentage of patients who get a repeat blood pressure if their first BP was greater than or equal to 140/90 from 32% to 54% by end of second quarter. MEASURE Once we determined what we will work to improve and begin taking steps to improve it we will need to re-measure to determine if our actions yield the results we desired. If we did not reach our goal we will need to reevaluate our actions and revise them as necessary. Sometimes you may not reach your goal because you did not wait enough time before re-measuring. Make Changes After you re-measure ask you team what changes they can make to improve your results. Implement/test the changes. The Plan, Do, Study, Act or PDSA cycle is a method on planning your actions for quality improvement, doing the steps for improvement, studying or evaluating the outcomes and act to improve, revise or sustain the progress. The PDSA cycle is on-going. ACT PLAN Testing ideas before implementing change STUDY DO Langley et al. , The Improvement Guide, 1996

Accurate Blood Pressure Measurement

Hypertension Measurement Video Click here for a short video on proper techniques for taking a blood pressure from New England Journal of Medicine. We will watch a short video that covers the proper techniques for taking blood pressures. Some of this information may be new to you; however, most of it will be familiar to you. We want to show the video so we all have the same base of knowledge. There is an 8 question knowledge check after the video. You may want to give your staff the questions to review/ answer while they watch the video. See appendix “Blood Pressure Measurement Post-Test”

for Blood Pressure Measurement Post-Test Knowledge Check CLICK HERE for Blood Pressure Measurement Post-Test Activity: Distribute the “Blood Pressure Measurement Post-Test” to all staff if you did not distribute to your staff prior to watching the video. Allow staff time to complete the post test. Click the “CLICK HERE FOR Blood Pressure Measurement Post-Test” button on your screen to pull up the BP post test. Go around the room and have staff answer each question out loud as a group. Use your answer key to confirm correct answers. If a staff member answers incorrectly help them discover the correct answer in a non-punitive manner. Answers to BP Knowledge Check Questions A B E C

What are the errors in this picture? What do we see in this picture as errors in blood pressure measurements: Allow staff to give answers. Staff should be able to identify the following as errors: Wrong cuff size Placement of cuff over sleeve OR pulling up sleeve Feet crossed (NOT flat on the floor) Patient is standing Arm is not heart level Staff member eyes are not level with sphygmomanometer Staffing placing the stethoscope over the sweater

Common Errors in Blood Pressure Measurement Wrong cuff size Placement of cuff over sleeve OR pulling up sleeve Feet crossed (NOT flat on the floor) Patient sitting without back support Arm in incorrect position (NOT at the heart level) Talking during BP measurement Eyes not level with manometer Patient has a full bladder Over-inflation of cuff Other common errors when taking a blood pressure consist of : Wrong cuff size Placement of cuff over sleeve OR pulling up sleeve Feet crossed (NOT flat on the floor) Patient sitting without back support Arm in incorrect position (NOT at the heart level) Talking during BP measurement Eyes not level with manometer Patient has a full bladder Over-inflation of cuff

Repeat Blood Pressure Measurement

Why Wait and Repeat Blood Pressure Studies show changes of 10 mmHg in SBP by waiting 5- 10 minutes after the patient sits down for BP check. Major trials evaluating the effects of blood pressure control on heart attack and death have patients wait 5 minutes. At one health system, we found that 30% of patients with initial BP > 140/90 had a normal BP (<140/90) after re-check. Repeating the BP helps providers know if they really need to intensify BP medication and avoids overtreatment. Read slide and allow time for comments.

Study: Alerting reaction and rise in blood pressure during measurement by physician & nurse The first graph is change in systolic blood pressure over time and the second graph is change in diastolic blood pressure over time. This graph demonstrates two things: Doctors often obtain higher BP measurements compared with nurses due to the white coat effect. Since nurses are usually the ones measuring blood pressure in the majority of trials, it is best to use medical assistants or nurses when checking blood pressure in the office. Most blood pressure lowering effects occur in the first 5-10 minutes after waiting, and the BP lowering effects of resting are substantial. Alerting reaction and rise in blood pressure during measurement by physician and nurse. Mancia G, Parati G, Pomidossi G, Grassi G, Casadei R, Zanchetti A. Hypertension. 1987 Feb; 9(2):209-15.

Hypertensive Adults with Elevated Blood Pressure This is an example graph of data from one of our clinics. This graph shows how the practice is doing in getting their patients blood pressure under control. For this graph LOWER is better; You will want to have fewer patients with an elevated blood pressure. Insert your clinic’s graph onto this slide for the percentage of adults (≥ 18 years old) with hypertension on the problem list and were seen in the last month where blood pressure is > 140/90mmHg. Include at least 2 months of baseline data.

Two BP Readings When 1st Elevated Insert baseline data for your clinic. This graph describes the percent of adults with hypertension and elevated blood pressure seen in the last month with two blood pressure readings if the first reading was elevated (≥ 140/90 mmHg) For this graph HIGHER is better. You will want to have your patients BP rechecked if the first BP was >140/90mmHg.

Two BP Readings When 1st Elevated What is the current process? How is it working? How could it be enhanced? Develop a goal for repeat BP readings. Ideas from other clinics EHR alert reminder when 1st BP is elevated Reminder poster at computer station BP notification magnet Discuss the 3 bulleted questions on the slide, and develop a goal for repeat BP readings. If your practice is not at 80% for two BP readings when the first one is elevated discuss what actions the practice can take to improve this measure.

Treatment Algorithm

Hypertension Treatment Algorithm Initial therapy with a low dose ACE/diuretic or ARB/diuretic combination IS BLOOD PRESSURE CONTROLLED? Yes No Continue with Current therapy Up-titration of combination therapy successively to the highest dose Yes No Add calcium channel blocker and up-titrate Continue with current therapy This is a recommend treatment algorithm that consist of once daily low cost medication. If your practice has a particular treatment algorithm approved for your organization you may insert it on to this slide. Yes No Continue with current therapy Add an -blocker,  blocker or spironolactone Feldman R D et al. Hypertension 2009; 53 646-653

Next Steps Repeat BP measurement Finalize treatment algorithm Timely follow-up will be discussed in session 3 Discuss next steps to improve the repeat blood pressure measure with staff. Re-measure results next month and share with team Medical leadership should finalize BP treatment algorithm. Next session (session # 3) will discuss strategies for timely follow up in greater detail.

Disclaimer Use of these slides alone will not improve blood pressure control within your practice. Blood pressure control will be achieved through active quality improvement efforts in conjunction with these slides. Practice coach consultation is available to assist you in improving outcomes.

Acknowledgements This work was made possible with funding from: The Mount Sinai Health Care Foundation U.S. Centers for Disease Control and Prevention Special thanks to: Better Health Partnership participating clinics Health Improvement Partnership-Cuyahoga (HIP- Cuyahoga)

Contact Info For questions about the online toolkit or assistance with implementation, please contact our coaching team: info@betterhealthpartnership.org.

Discussion/Questions? Thank You! Discussion/Questions?