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2. Million Hearts® 2022 and Best Practices for Hypertension Control
Adriane Burke
Health Systems Coordinator
New Hampshire Division of Public Health Services
Georgette Verhelle, RN, BS, CPHQ Program Coordinator, New England QIN-QIO

3. The Million Hearts® Initiative in New Hampshire
Adriane Burke
Health Systems Coordinator
New Hampshire Division of Public Health Services
October 26, 2017

14. Accurate Blood Pressure Measurement Saves Lives: Best Practices
Presented By:
Georgette Verhelle, RN, BS, CPHQ
New England QIN-QIO

15. Objectives To list the classifications of blood pressure.
To use correct patient positioning for an accurate BP measurement.
To be able to select the correct size BP cuff for accurate measurement.
To identify at least 3 lifestyle modifications that you can discuss with patients who have prehypertension or hypertension.

16. What is Blood Pressure (BP)?
The force of blood against the walls of the arteries
BP is recorded as 2 numbers:
Systolic: the force exerted when the heart contracts
Diastolic: the force exerted when the heart relaxes
Hypertension is persistently high BP

17. BP Classification Blood Pressure Category Systolic mm Hg (upper #)
Diastolic mm Hg (lower #)
Normal
less than 120
and
less than 80
Prehypertension
middle
120 – 139 or
80 – 89
High Blood Pressure (Hypertension) Stage 1 middle
140 – 159
90 – 99
High Blood Pressure (Hypertension) Stage 2
160 or higher
100 or higher
Hypertensive Crisis (Emergency care needed)
Higher than 180
Higher than 110

18. Why is this Important?
“In 2013, high blood pressure was a primary or contributing cause of death for more than 360,000 Americans – nearly 1,000 deaths per day.” (Million Hearts®)
Hypertension increases one’s risk of heart disease, stroke, kidney disease, and early death.
1 in 3 US adults have high blood pressure and only half have their condition under control.
Inaccurate blood pressure measurement can lead to misdiagnosis of hypertension.

19. Patient Positioning Feet flat, legs uncrossed Back supported
Arm exposed & level with heart
No talking during measurement
Avoid smoking 30 minutes prior to measurement
Avoid full bladder

20. Arm Selection Avoid taking BP on the side that has/had: Pain or injury
Breast or axilla surgery including Mastectomy
Lymphedema
Dialysis Shunt/Fistula
Subclavian Stenosis (narrowing/constriction)
IV/arterial line

21. Check Equipment Calibrate according to manufacturer's directions
Visually inspect before use
The needle on the sphygmomanometer must be within the zero box prior to inflation or take the unit out of service until fixed

22. Selecting the Correct Cuff Size

23. Cuff too Big Cuff too Small index line left of range
reading will be inaccurately low
Cuff too Small
index line right of range
reading will be inaccurately high

24. Correct Cuff Size Correct Placement Index line within range
Apply the cuff snugly around arm,1 inch above antecubital fossa.

25. AVOID:
Artifactual Sounds
Tourniquet Effect
Muffled Sounds

26. The Cost of Making Small Measurement Errors
Small errors may result in either…
undiagnosed cases of hypertension (undertreated)
misdiagnosed cases of hypertension in patients who are really pre-hypertensive (over-treatment)

27. Factors Affecting Accuracy of Blood Pressure Measurements

28. Obtaining and Recording an Accurate Blood Pressure
Obtain BP Reading: apply cuff snugly around arm, 1 inch above the antecubital fossa. Inflate cuff, then deflate at 2 – 3 mmHg/sec.
Note systolic pressure: 1st two or more consecutive faint tapping beats (Korotkoff sound, phase 1)
Note diastolic pressure: last sound heard or disappearance of sound (2mmHg below the last sound)
Both methods are recognized standards: refer to your agency’s policy & procedure
Listen for another 10 – 20 mmHg beyond last sound heard, then quickly deflate cuff to zero.

29. Obtaining and Recording an Accurate Blood Pressure
Record and Recheck as Needed:
Record BP, rounding up to the nearest 2mmHg
Wait at least 5 minute between BP readings
Notify provider of all readings of concern (some agencies have a policy that an RN will recheck prior to this step)
Always follow your agency’s BP Policy & Procedure

30. What Can Your Practice Do to Ensure Accurate BP Measurements?
Develop a BP policy & procedure
Provide staff training
Do competency testing
Calibrate BP equipment
Rearrange furniture in exam rooms to accurately take a BP
Position patient properly

31. Lifestyle Modifications to Discuss with Patients
Always take BP medication as prescribed – don’t stop or skip a dose without consulting with your provider
Maintain normal body weight
Eat a healthy diet: high in fruits/vegetables, low in fat, reduce salt intake
Physical Activity: at least 30 minutes, most days
Avoid tobacco
Limit alcohol use
Manage stress/diabetes
Have BP checked regularly & consider self-monitoring

32. Name at least 4 of Judy’s risk factors
Case Study
Judy is a 50 yo African American woman who is 5’2” (62”) and weighs 180lbs (BMI = 33). She is an administrative assistant at a large insurance agency and does not exercise on a regular basis. She is a diabetic and smokes 1 pack of cigarettes/day. Her BP was 180/92 today.
Name at least 4 of Judy’s risk factors

33. List 3 lifestyle modifications that Judy can try to lower her BP
Case Study
Judy is a 50 yo African American woman who is 5’2” (62”) and weighs 180lbs (BMI = 33). She is an administrative assistant at a large insurance agency and does not exercise on a regular basis. She is a diabetic and smokes 1 pack of cigarettes/day. Her BP was 180/92 today.
List 3 lifestyle modifications that Judy can try to lower her BP

34. Lifestyle Modifications to Discuss with Patients
Always take BP medication as prescribed – don’t stop or skip a dose without consulting with your provider
Maintain normal body weight
Eat a healthy diet: high in fruits/vegetables, low in fat, reduce salt intake
Physical Activity: at least 30 minutes, most days
Avoid tobacco
Limit alcohol use
Manage stress/diabetes
Have BP checked regularly & consider self-monitoring

35. Acknowledgements
The material presented was originally developed by Dr. Rudolph Fedrizzi, Director of Community Health Clinical Integration and the Education, Training and Development Department at Cheshire Medical Center/Dartmouth-Hitchcock in Keene. Thank you for sharing the slides and allowing us to use some of the pictures/content for this program.
Also thank you to the New Hampshire DPHS for their contribution to this presentation.
Updates have been made to some slides using information from the Million Hearts® website and the American Heart Association website.

36. References
Department of Health and Human Services, Maine. (July 2010). Maine health care systems intervention to improve the detection and control of high blood pressure. A story from the field, 1-30.
Education, Training and Development Department. Obtaining Accurate Blood Pressure Measurements In The Ambulatory Setting. Keene, NH: Cheshire Medical Center and Dartmouth Hitchcock.
New Hampshire Medical Society. (2011). To Control Your High Blood Pressure You Need To…Know Your Numbers. Keene, NH: Cheshire Medical Center and Dartmouth Hitchcock.
New Hampshire Medical Society. (2011).When it Comes to Blood Pressure You Need To…Know Your Numbers. Keene, NH: Cheshire Medical Center and Dartmouth Hitchcock.

37. References
Quality Improvement Organizations. (2012). QIO tool kit: Reducing Cardiac Risk Factors, 1-41.
Utah Department of Health. (July 2006). Blood Pressure Measurement: Standardization Protocol, 1-41.
Washington State Department of Health. (August 2013). Improving the screening, prevention, and management of hypertension. An Implementation Tool For Clinic Practice Teams,
Wisconsin Department of Health Services. Blood Pressure Measurement Toolkit: Improving Accuracy, Enhancing Care,1-28.

38. Contact Information
Georgette Verhelle, RN, BS, CPHQ (603)

39. Self-Measured Blood Pressure Program

40. What is Self-Measured Blood Pressure ?
SMBP is the regular measurement of blood pressure by the patient outside the clinical setting, either at home or elsewhere. SMBP requires the use of a home blood pressure measurement device by the patient to measure blood pressure at different points in time.
There is strong evidence to support the use of SMBP especially when tied with clinical support.

41. Benefits of SMBP Monitoring
SMBP yields many results over time with fewer office visits:
Can help determine if a change in therapy is needed
It can prevent over-treatment
Improves BP control, especially when used with clinical support
When SMBP monitoring interventions were combined with additional support, systolic blood pressure decreased by an average of 4.6 mmHg and diastolic blood pressure decreased by an average of 2.3 mmHg (Community Guide).
Improves adherence to antihypertensive therapy

42. *Graphic from Million Hearts webpage

43. Hypertension at NH FQHC’s
Data Source: 2015 UDS Data of New Hampshire FQHCs:

44. Recommendations The Community Guide (2015)
SMBP when used alone – Recommended
SMBP when combined with additional support – Recommended
Agency for Healthcare Regulation & Quality Comparative Effectiveness Study (2012)
Evidence is high showing the effectiveness of SMBP with additional clinical support in lowering blood pressure and improving control among patients with hypertension, compared with usual care.
United States Preventive Health Services Task Force (2015)
“A Level Recommendation” for screening for high blood pressure in adults aged 18 years or older. Obtaining measurements outside of the clinical setting for diagnostic confirmation before starting treatment is recommended using ABPM or SMBP.

45. Joint Scientific Statement
A Joint Scientific Statement from AHA, ASH, and PCNA encourages increased regular use of SMBP by clinicians for the majority of patients with known or suspected hypertension as a way to increase patients’ engagement and ability to self-manage their condition.
AHA- American Heart Association
ASH – American Society of Hypertension
PCNA - Preventive Cardiovascular Nurses Association
Pickering TG, Miller NH, Ogedegbe G, Kra-koff LR, Artinian NT, Goff D. Call to action on use and reimbursement for home blood pressure monitoring: executive summary: a joint scientific statement from the Ameri-can Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. J Am Soc Hypertens. 2008;2:192–202

46. Additional Support for SMBP Monitoring
Other organizations who do not have a formal recommendation but support the use of SMBP through various initiatives include:
Million Hearts®
American Medical Association
American Heart Association
CDC’s 6/18 Initiative

47. SMBP Program in New Hampshire
There is evidence to support the use of SMBP
Insurance coverage of monitors is “spotty” and unclear.
There was an identified need in the state
NH DPHS was able to obtain funding for monitors and partnered with the NE QIN/QIO to help implement a program.

48. Getting Started
Clinics who were already doing HTN QI projects through grants/contracts with the state were targeted as pilot sites
Each clinic had to apply and be accepted into the program
Monitors sent to clinics September 2016
Clinics started the program once they had their procedure manual developed.
13 clinics are participating

49. Program Requirements
Develop a written procedure which outlines the program and meets specific requirements
Identify patient education materials
Report back data at 6 months and 12 months:
Number of patients receiving monitors and reason
Number of patients who reported their blood pressures back to the clinic at least once?
Number of patients who had a reduction in blood pressure
Number of patients now in control (below 140/90)
Any challenges and success

50. Resources
We encouraged using these resources as good examples of how a program should look

51. # of patients with a reduction in BP
Six month results
Data is starting to roll in and the results are exciting!
Clinic
# of patients enrolled
# of patients with a reduction in BP
# of patients below 140/90
Clinic A 31 24 15
Clinic B 26 20 14

52. Next Steps: Phase 2 Phase 2 applications are now available.
If you are interested in Phase 2 send an to or and we’ll send you an application.

53. Adriane.Burke@dhhs.nh.gov (603) 271-1075
Thank you!
(603)

54. Questions?
This material was prepared by the New England QIN-QIO, the Medicare Quality Innovation Network-Quality Improvement Organization for New England, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. CMSQINB