590 - A Quality Improvement Initiative to Improve Identification and Diagnosis of Pediatric Hypertension in a Primary Care Setting

Poster Number: 590
Publication Number: 590.208

Vildan Tas, Arkansas Children's Hospital, Little Rock, AR, United States; Rachel Achor, Arkansas Children’s, Little Rock, AR, United States; Richard T. Blaszak, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; brendan Crawford, Arkansas Children's Hospital, 1 childrens hospital, AR, United States; Mohammad Ilyas, UAMS, Little rock, AR, United States; James S. Magee, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; Debra D. Becton, UAMS, Little Rock, AR, United States; Linda Mars, Arkansas Children's Hospital, Litttle Rock, AR, United States; Kelley N. Means, Arkansas Children’s Hospital, Conway, AR, United States; AnnMarie Neal, Arkansas Children's Hospital, Little Rock, AR, United States; Marcus D. O'Brien, Arkansas Children's Hospital, Little Rock, AR, United States; Laura L. Sisterhen, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States

Background: The 2017 American Academy of Pediatrics (AAP) guidelines for identification of hypertension (HTN) highlight proper techniques for accurate diagnosis, emphasizing the importance of proper cuff size (measuring mid-arm circumference (MAC) to ensure fit), standardized cuff location (right arm) and verification of abnormal oscillometric readings by auscultation method. In busy primary care settings, health care teams likely deviate from practice guidelines, leading to the missed diagnosis of HTN.

Objective: This initiative focused on implementing an evidence-based practice bundle for blood pressure (BP) measurement to improve adherence to guidelines and identify HTN.

Design/Methods: A review of the literature and discussion with key stakeholders identified several barriers to the accurate diagnosis of pediatric HTN. Interventions were designed to address barriers to accurate BP screening, such as annual training of clinical staff on proper BP measurement techniques, faculty/resident education on the AAP HTN guidelines, and an electronic health record (EHR) practice advisory alerting staff of an elevated BP reading. Interventions conformed to standard PDSA cycles. The charts of patients 13-20 years of age seen in the Arkansas Children’s Hospital primary care settings between November 2020 and December 2021 with a BP >120/80 within the last three months were reviewed for documentation of a diagnosis of either HTN or elevated BP. Additional data gathered included BP cuff location, measurement of MAC, and the presence of a second auscultatory BP for those patients with an initially elevated BP.

Results: Documentation of elevated BP or HTN in the problem list improved from 16% (41/252) to 44% (110/252) with the improvement of all process measures; adolescent patients with an abnormal BP who had BP measured in the right arm from 67% (170/252) to 91% (297/325), documentation of MAC measurement from 9% (58/633) to 37% (121/331), and second BP measurement from 44% (110/252) to 79% (262/331). Conclusion(s): Accurate measurement of BP remains a challenge in primary care settings. Improving the accuracy of BP screening required nurse education regarding clinical importance, provider refreshers on HTN guidelines, and providing regular feedback on performance. To further improve the implementation of HTN guidelines; nursing leaders will consider incentives for adherence to the BP bundle and a template and order set to assist providers with EHR documentation will be created.
Key Driver Diagram
Documentation of Hypertension Diagnosis in the Patient Chart