P2D255: Detection and Disposition of Patients with Elevated BP in Subspecialty Clinics

Purpose/Objectives: Hypertension is one of the top five chronic diseases in children and adolescents. Yet, pediatric hypertension is missed in up to 75% of pediatric patients in primary care settings. This prompted us to improve identifying patients with elevated blood pressure in our subspecialty clinics. Following diagnostic criteria set forth by the 2017 AAP’s Pediatric Hypertension Practice Guidelines, this project aimed to identify and address deficiencies in measuring, documenting, and interpreting blood pressure (BP) and addressing patients with an elevated BP reading with appropriate measures at multi-specialty pediatric ambulatory care center at St. Joseph’s Children’s Hospital.

Design/Methods: We utilized the Quality Improvement (QI) and serial PDSA method (Plan-Do-Study-Act) to test changes, which we predicted would improve to identify and address patients with elevated BP. We focused our QI in 4 pediatric subspecialty ambulatory clinics: Neurology, GI, Endocrinology, and Pulmonology. Subjects were patients aged seven years and above. Patients with established hypertension were excluded.
-Baseline pre-study: Data were collected to ascertain the rate of patients with uncharted BP and patients with charted elevated BP not addressed.
-First cycle: Trained medical assistants identified and documented patients with elevated BP as defined by the AAP guidelines after measuring BP twice and using appropriate measuring techniques.
-Second cycle: Medical assistants alerted physicians seeing patients with elevated BP by placing a sticky note on the examination room doors.
-Third cycle: Medical assistants notified primary care doctors of patients with elevated BP by fax letter.
-Fourth cycle: We contacted PMD offices to inquire whether they had received the fax letter and if any action was taken.

Results: This project showed that trained medical assistants requested to take BP in children resulted in the documentation of BP readings in 100% of the children. Flagging elevated BP using current guidelines criteria and notifying pediatric subspecialty physicians improved acknowledgment of the high BP readings in only a little less than 25% of the patients. Medical assistants’ implementing direct notification by letter of the primary care doctors caring for the children noted to have elevated BP in the subspecialty clinic led to further improvement of detection and disposition: Over 50% of primary care doctors acknowledged having received the notification, and 50% of the 45 patients with elevated BP received appropriate evaluations.

Conclusion/Discussion: We showed that adhering to current BP guidelines to detect children with elevated BP, empowering trained medical assistants to flag abnormal BP readings, and involving patients’ primary care doctors to address their patients’ elevated BP by direct letter notification improved the rate of children receiving evaluations. Developing novel yet simple procedures like this one may help to further increase the identification and evaluation of children with abnormal BP seen in subspecialty clinics in the future.