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

2. 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): and CDC community guide task force 2015

3. 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

4. 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:
Parati G, Stergiou GS, Asmar R, et al. European society of hypertension practice guidelines for home blood pressure monitoring. J Hum Hypertens 2010;

5. 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

6. 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

7. 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: British Hypertension Society website:

8. 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

9. 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

10. 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.

11. 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

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

13. 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 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.

14. 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

15. 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): doi: /jama

16. Tools and resources to enhance SMBP
hypertension-blood-pressure-control

17. 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

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

19. 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

20. 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

21. 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)

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

23. 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

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

25. 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

26. 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

27. 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

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

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

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

31. Questions?

32. Linda Murakami, RN, BSN, MSHA