Self-measured blood pressure monitoring Linda Murakami, RN, BSN, MSHA Senior Program Manager, Quality Improvement

Self-measured blood pressure There is sufficient evidence of the effectiveness for SMBP to improve BP when used alone (training provided for proper use and communication) There is strong evidence for the effectiveness of SMBP when combined with additional support (i.e., patient counseling, education or web-based support) Uhlig K, Patel K, Ip S, et al. Self-measured blood pressure monitoring in the management of hypertension. Annals of Internal Medicine 2013, 159(3): 185-194. and CDC community guide task force 2015

Implementing a SMBP program What do we need to get started? Identify staff to manage the program Identify staff to train patients Patient selection criteria Process to communicate readings from the patient back to the office Process in place to act on readings that are above or below an acceptable range

Implementing a SMBP program SMBP improves adherence to therapy Empowers patient to be more involved to self-manage Improves medication adherence with clinical support Sharman JE, Howes FS, Head GA, et al. Home blood pressure monitoring: Australian expert consensus statement. Journal of Hypertension 2015; 33: 1721-1728 Parati G, Stergiou GS, Asmar R, et al. European society of hypertension practice guidelines for home blood pressure monitoring. J Hum Hypertens 2010; 779-785

Implementing a SMBP program Patients without a diagnosis of HTN: Patients with elevated office BPs who are suspected of having HTN (to make Dx) Suspected white coat hypertension Suspected masked hypertension Patients with a diagnosis of HTN Any patient- increase engagement, adherence to treatment or improve BP control To assess treatment effect on BP control Difficult to control BPs to determine if treatment resistant HTN is present

Implementing a SMBP program Recommend a validated automated upper arm BP monitor (with memory and averaging preferred) Do not recommend a wrist cuff (unless brachial readings impossible) Finger devices should never be used Appropriate fitting cuff essential (learn how to teach patients to measure) Many devices have multiple cuff options

Implementing a SMBP program Validated Device: European Society of Hypertension International Protocol (ESH) British Hypertension Society Protocol (BHS) Association for the Advancement of Medical Instrumentation Protocol (AAMI) List of validated home blood pressure monitors: Dabl Educational Trust website: www.dableducational.org British Hypertension Society website: www.bhsoc.org/bp-monitors/bp-monitors/

Frequency of self-measurement For initial evaluation, and assessment of change in medication, perform SMBP for seven consecutive days (3 minimum) Measure daily morning and evening before taking medication Each measurement should be in duplicate 1-2 minutes apart Discard the first days readings and average the remaining if taking 4 or more consecutive days This should be performed for one week prior to each office visit Less frequent checks are necessary in a patient with stable controlled BP though more frequent checks may be used for engagement

Interpreting self-measured blood pressure readings What are normal BPs using SMBP? BPs < 130/80 mm Hg are considered normal What is HTN or Uncontrolled BP using SMBP? BPs > 135/85 mm Hg are considered elevated

Closing the SMBP data loop Centers for Disease Control and Prevention. Self-Measured Blood Pressure Monitoring: Actions Steps for Clinicians. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2014.

Closing the SMBP data loop Share SMBP with physician’s office Telephone Secure fax Online through secure patient portal or telemedicine website Bring device to the office for staff to review measurements or download if measurement storage is available Follow-up office visit

Closing the SMBP data loop An example of a secure telemedicine site is the American Heart Association’s Heart360 tool www.heart360.org What the clinician sees What the patient sees

Closing the SMBP data loop One-on-one counseling Telephone calls from RNs to manage medications Counseling sessions with pharmacists Web-based or telephone support based on patient-reported SMBP readings Computer telephone-based feedback system Secure patient website training plus pharmacist care management via web communication Access to web-based tools for med refill requests, text and e-mail reminders to measure BP or for appointments, secure messaging with clinician or staff Centers for Disease Control and Prevention. Self-Measured Blood Pressure Monitoring: Actions Steps for Clinicians. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2014.

Closing the SMBP data loop About half of the intervention effect in this multifaceted trial to improve hypertension control was attributable to the combination of self-monitoring and medication intensification. J Gen Intern Med 30(11):1665–72

Closing the SMBP data loop Among hypertensive patients at high risk of cardiovascular disease, self-monitoring with self-titration of antihypertensive medication, compared with usual care, resulted in lower systolic blood pressure at 12months. JAMA. 2014;312(8):799-808. doi:10.1001/jama.2014.10057

Tools and resources to enhance SMBP www.stepsforward.org/modules/ hypertension-blood-pressure-control www.ama-assn.org/go/improving-bp-control

Tools for clinical team education Tools and resources to enhance SMBP Tools for clinical team education Measuring accurately: SMBP Clinical Competency: Patient SMBP at home Measure accurately: A guide for BP measurement How to check a home BP monitor for accuracy

Tools and resources to enhance SMBP Clinical Competency: Patient SMBP at home

Training patients to self-measure accurately Prior to measuring: For 30 minutes No exercise, large meals, caffeine, alcohol, nicotine, decongestants Empty bladder if needed, then rest for 5 minutes sitting comfortably

Training patients to self-measure accurately During the measurement: Continue to sit with back supported, legs uncrossed and feet flat on the floor Following the instructions for your device, put the cuff on by wrapping it around your bare arm 2-3 cm above the elbow Face the palm of hand up to relax arm muscles Rest arm on a table or another flat surface at the level of the heart No talking, reading, texting or watching TV during the measurement Continue to follow directions of the monitor, pressing the start button to begin

Training patients to self-measure accurately After the measurement: The date, time, systolic and diastolic BP and pulse should be recorded immediately Wait one minute and repeat (always take at least two readings in a sitting) Remove the cuff and place the device in a safe and dry place. Clear Instructions must be given for the patient to follow for communicating blood pressures (especially high, low, or BPs associated with symptoms)

Tools and resources to enhance SMBP A guide for blood pressure measurement Discusses common issues that can lead to inaccurate blood pressure measurement

Tools and resources to enhance SMBP SMBP Device Loaner Program Patient selection criteria for a blood pressure monitor loaner program Patient enrollment process for a blood pressure device loaner program Patient participation and blood pressure device loaner agreement Recommended infection prevention process for blood pressure monitors loaned to patients BP monitor loaner log

Tools and resources to enhance SMBP Diagnosis, communication, documentation and management Highlights guidance on each of these topics

Tools and resources to enhance SMBP Tools for patients Self-measured blood pressure at home patient guide Importance of self-measuring blood pressure Choosing a home blood pressure monitoring device Measuring your blood pressure accurately

Tools and resources to enhance SMBP Tools for patients High blood pressure (hypertension) overview: provides information on hypertension, types of hypertension symptoms and treatment in words the patient can understand

Tools and resources to enhance SMBP Tools for patients Self-measured blood pressure at home: Gives the patient information about measuring their blood pressure, selecting a device and cuff size selection

Tools and resources to enhance SMBP Tools for patients At-home measurement graphic

Tools and resources to enhance SMBP Tools for patients Patient blood pressure measurement flow sheet

Tools and resources to enhance SMBP Tools for patients Patient blood pressure measurement wallet card

Questions?

Linda Murakami, RN, BSN, MSHA linda.murakami@ama-assn.org 312-464-4638