Background: Hypertension occurs in up to 75% of hospitalized patients. However, less than 1% have “hypertensive emergency,” defined as severely elevated blood pressure (BP) with end-organ injury. Current guidelines support emergent treatment of hypertensive emergency but recommend against immediate reduction of severely elevated BP in patients without end-organ injury (i.e., asymptomatic hypertension). Recent literature suggests that “as-needed” (i.e., PRN) anti-hypertensives provide no medical benefit, are harmful, and lead to excess health care expenditure.
Purpose: The aim of this initiative is to reduce the use of PRN anti-hypertensives in hospitalized adults with hypertension without end-organ injury (“asymptomatic hypertension”). We implemented a multi-modal intervention, which included educational initiatives and electronic health record (EHR) modifications. Education about evaluation and management of hypertension in hospitalized patients was provided to physicians, pharmacists, and nurses. EHR modifications included removing PRN anti-hypertensives from admission order sets and increasing default BP notification parameters.
Description: The study population in the pre-intervention period (July 2021 – September 2021) included adults with at least 1 elevated BP, defined as systolic BP (SBP) > 140 mmHg or diastolic BP (DBP) > 80 mmHg, admitted to medical services at an academic institution. Adults with hypertensive emergency, or diagnoses necessitating strict BP control (e.g., aortic dissection, intra-cranial hemorrhage, acute pulmonary edema), were excluded. Over the 3-month period, there were 1,091 encounters associated with at least 1 elevated BP. PRN anti-hypertensive orders were documented in 15% of encounters, and 6% of encounters were associated with at least 1 administration. PRN anti-hypertensives were administered at least 10 times in 11 encounters.In total, 144 providers, pharmacists, and nurses completed a pre-intervention survey related to attitude about and knowledge of evaluation and management of hypertension in hospitalized patients. Nearly 40% of providers reported being “Extremely confident” in their ability to differentiate hypertensive emergency from asymptomatic hypertension, whereas less than 20% of nurses and pharmacists reported feeling ‘”Extremely confident” (Figure 1A). Most providers (79%) perceived that patients were “Sometimes” or “Rarely” evaluated for secondary causes of hypertension, but more than 50% of nurses perceived that patients were “Often” or “Always” assessed (Figure 1B). The mean reported BP threshold for administering PRN anti-hypertensives was higher for providers compared to nurses and pharmacists (Figure 1C). The most common reasons reported by nurses for administering PRN anti-hypertensives were to treat hypertension (32%) and maintain BP within pre-specified parameters (26%). Nearly 40% of providers reported ordering PRN anti-hypertensives to prevent pages from nurses (Figure 2).
Conclusions: Though hypertensive emergency is rare, PRN anti-hypertensives are frequently ordered and administered in the inpatient setting. This may be due to lack of knowledge about evaluation and management of hypertension in hospitalized patients. It may also be related to efforts to minimize workflow disruptions (e.g., paging). Post-intervention data is being collected to evaluate the efficacy of a multi-modal intervention to decrease the use of PRN anti-hypertensives in asymptomatic patients at our institution.
