Abstract
Improving the assessment and management of blood pressure in older populations
Introduction
Managing blood pressure in patients above 65 years old remains controversial with limited evidence in relation to balancing cardiovascular benefit and risks of postural hypotension. National guidelines highlight appropriate medications and contraindicated drugs. An initial audit identified a large proportion of elderly Wigan borough residents being on inappropriate medication alongside poor compliance in assessing and managing abnormal blood pressure. This quality improvement project aims to increase clinician knowledge and improve assessment and management of antihypertensives and blood pressure in older populations.
Methods
We retrospectively analysed summary care records of 54 patients over the age of 65, admitted under the care of the Ageing and Complex Medicine team, with diagnoses related to postural hypotension, hypertension and falls. Metrics interrogated included documentation of LSBP on admission and appropriateness of blood pressure medication on admission and subsequently on discharge 3 PDSA cycles were undertaken. These targeted senior clinicians within the trust, the Care of the Elderly MDT and new junior doctors.
Results
There was no improvement on measurement of LSBP on admission (Baseline 67%, Implementation 1: 55%, Implementation 2: 27%, Implementation 3: 50%). There was some improvement in percentage of patients discharged on appropriate medications as compared to admission (Baseline 12%, Implementation 1: 5%, Implementation 2: 0%, Implementation 3: 10%). Average confidence rating in junior doctors managing anti-hypertensives and postural hypotension. significantly improved from 2.5/5 to 4/5 pre vs. post teaching session.
Conclusion
Although teaching sessions were delivered to clinicians all all levels and this improved doctor's confidence in blood pressure management, this did not translate to any tangible improvements in LSBP monitoring on admission/ discharge nor the selection of appropriate medications. Further interventions to improve LSBP monitoring and documentation, medication reviews and MDT education are ongoing.
Comments
Further plans
Many thanks for submitting your work, getting L/S BP recordings is a challenge in many acute care settings. I was wondering where you thought your teaching would be best targeted to improve this? Have you enquired about electronic prompts too, or is this still under consideration?
Thank you very much for your question. We agree that getting LSBP is indeed a challenge in acute care settings.
Several factors to contribute
- inefficient verbal and technology communication between physiotherapists, nurses, doctors
- patient factor, not compliant, immobile etc
- Systems issue - difficulty recording accurate data
- clinician inertia due to time and service pressures
Improvement points
- Teaching higlights the above factors to prompt clinicians to ensure LSBP is relayed to OTPT and nursing teams in a timely manner during their handover in the morning
- Teaching reinforced the need for uniform documentation in the observations section of documentation section, to record LSBP at 0 minutes and 5 minutes
- Teaching to higlight importance and relevance of recording LSBP in the management of blood pressure in the older people.
We are also currently working on changing the systems for a more visible and easy to input section for LSBP to improve ease of documenting and assessing LSBP. In terms of electronic prompts we are in discussion of the careful balance between highlighting LSBP to clinicians electronically vs. preventing further inefficiencies/ check box exercises on the system that clinicians have reduced attention to.