Hypertension is a risk factor for cardiovascular disease which is a leading cause of death in the United States (Centers for Disease Control [CDC], 2014; Coogan, Marra, & Lomonaco, 2015). Although approximately one-third of the adult population has hypertension, almost one-half of those diagnosed are not meeting target blood pressures of less than 140/90 (CDC; Coogan et al.). Proper diagnosis and management of hypertension is based on blood pressure readings. Correct blood pressure measurement technique by staff is critical (American Association of Critical-Care Nurses, 2016; Bland & Ousey, 2011; Coogen et al.; Giorgi, & Ganem, 2016; Rabbia et al., 2013; Vieira da Silva, Mendes da Silva, 2016). Error in blood pressure measurements by staff can result in an incorrect diagnosis of hypertension or over/under treatment of the patient (Coogen et al.; Rabbia et al.; Vieira da Silva et al.). Education and evaluation of staff blood pressure measurement techniques has been shown to improve the accuracy of patient blood pressure readings (Ballard, Piper and Stokes, 2012; Coogan et al.; Garcia, Ahmad & Lim, 2012; Grim & Grim, 2013).
A rural health care organization sought to improve hypertension management of their patients. The organization’s target for achieving blood pressure of less than 140/90 in patients with a diagnosis of hypertension was set at 88% or greater. Since 2008 this quality metric had remained relatively unchanged with 71-74% of patients achieving blood pressure control as reported by Wisconsin Collaborative for Healthcare Quality (WCHQ). These percentages did not meet the organization’s target. Additionally, the organization’s ranking for blood pressure control among other state health care organizations was 13 of 21 and declining (WCHQ). A quality improvement project to address this issue was developed and initiated in 2014.
Methods and Findings
Recognizing the critical piece staff education and training play in management of patients with hypertension, the health care organization began mandatory blood pressure education for all medical assistants, registered nurses and licensed practical nurses performing blood pressure testing in the primary care areas in 2014. Staff were required to complete a yearly computer-based learning module that tested knowledge of correct procedure. In-person manual blood pressure testing using a simulation arm was done. Proper technique and accuracy of the reading were assessed. In addition, staff were required to measure a clinical staff educator’s blood pressure using an automatic blood pressure machine. Proper cuff size, placement, technique and positioning of the educator were assessed. If deficiencies were noted, immediate remediation was done. If staff could not accurately hear the manual blood pressure on the simulation arm, recommendations for possible hearing evaluations were sent to the manager.
In addition to educational requirements, the primary care staff began verifying the accuracy and correct technique for use of patient blood pressure home monitors. Patients were encouraged to bring in their home monitors at least yearly for comparison to a blood pressure taken either manually by staff or with the clinic’s automatic device. Once the home device accuracy and correct patient technique was verified, patient blood pressure home records could be entered into the electronic health record. Patients were given directions on testing technique, frequency and when to contact the provider with readings.
Utilizing the electronic health care record and the population health dashboard, reports listing patients aged 18-74 with a diagnosis of hypertension who were not meeting blood pressure goals of less than 140/90 were generated. Staff received education and training on how to generate reports and the management of these patients which included contacting patients for follow-up blood pressures or reporting home blood pressure measurements.
The results of the 2014 quality improvement project showed the percentage of patients aged 18-74 meeting target blood pressures of less than 140/90 had increased. WCHQ’s first report for 2015 showed an increase from 73% to 81% of patients in control (Quarter 3/14 to Quarter 2/15). In an effort to improve blood pressure management, an incentive program was initiated in 2015 with a small percentage of the primary care physician’s salary tied to achieving a minimum target of 82% of hypertensive patients in control. While primary care physicians were responsible for treating blood pressures greater than 140/90, they were not always aware of a patient’s increased blood pressure reading. If a patient had an elevated blood pressure in a specialty area, this blood pressure was recorded in the electronic medical record but the primary care physician was not notified. The organization recognized the need to expand participation in this quality improvement project to the entire organization. As a result, starting in January 2015, all of the organization’s staff performing blood pressure testing (excluding providers) received computer-based and in-person training using simulation and live subjects. An emphasis was also placed on the need to perform a second blood pressure measurement on all patients having an initial elevated blood pressure.
The increased number of staff needing training required a coordinated effort with the organization’s education department responsible for the training and the departments requiring education. The education department training assistant and educators worked with managers to set up in-person training times and places. Training was ideally done within the learner’s department, but was also done in classrooms. Thirty minutes of individual training time was allotted per learner.
The results of the 2015 quality improvement project showed patients meeting target rose from 81-82% (WCHQ). This did not meet the benchmark of 88%; therefore, the quality improvement project was expanded for 2016 to include specialty care areas. Staff testing continued to include all staff (excluding providers) performing blood pressure measurements on patients. In addition, staff in all areas were required to take a second blood pressure on patients having an initial blood pressure of 140/90 or greater. If the second reading was still 140/90 or greater, a referral to their primary care provider was mandated. The specialty care physicians were required to ensure this was done in order to receive their incentive bonus. There was also a potential for staff incentive if the organization’s budget allowed and hypertension targets were met. The primary care provider’s incentive would continue as per the previous year.
In an effort to meet this new initiative, computerized reports of patients not at target, reports of missing second blood pressure readings and missing referrals for elevated blood pressures were generated. Each provider was able to view these reports and staff were assigned to contact patients via phone call or letter for follow-up. All follow-up visits to recheck elevated blood pressure measurements were done free of charge.
The quality improvement project ended December 2016 with WCHQ reporting 85% of patients meeting blood pressure targets at that time, thus increasing the state’s organizational ranking to 6/24. Education of all staff performing blood pressures on patients continues. The organization continues to track patients not meeting hypertension goals.
Conclusions
The management of hypertension is essential in preventing cardiovascular disease and complications. Correct techniques utilized by staff measuring patient blood pressures are essential in correct diagnosis and treatment of hypertension. Through computer-based training, simulation, one-to-one education and staff incentive programs, one health care system improved patient blood pressure management outcomes 12% over a three year period of time. Recommendations for the future are to assess the percentage of patients meeting target blood pressures when incentivization is no longer used and to assess the rate of decay for proper blood pressure measurement by staff.
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