Hypertension screening:
Documentation and
Management
Washington Heights Family Heath Center
How well do we continue
to screen for hypertension
( HTN) and what are we
doing about it?
Definitions:
 Prehypertension:
 ≥ 90th percentile but < 95th percentile
 Stage 1 HTN:
 ≥ 95th percentile up to 5mmHg
above the 99th percentile
 Stage 2 HTN:
 ≥ 5mmHg above the 99th percentile
Rationale for focus on HTN in our practice
 Increased likelihood of HTN in
adulthood.1, 4
 Premature atherosclerosis2
 Early development of CVD3, 4
 Reduction of BP in adults reduces
cardiovascular morbidity and mortality.3
 Screening occurs in outpatient setting
Aim Statement
 To (re-) educate 100% of providers on the NHBPEP guidelines
for BP screening
 To maintain ≥ 95% rate of BP measurement for all children > 3yo
during their annual WCC
 To increase BP percentile (BP%) documentation to ≥ 95% for
original and repeat BPs
 To have > 80% of provider acknowledge and categorize staging of
elevated BP
 To create an ACN-specific algorithm for follow up and referral of
children with elevated BP, and to have > 80% of providers follow
such an algorithm
Baseline Data
Total WCC: 119
BP Documented
95% (113/119)
BP Percentile
Documented:
80% (90/113)
BP > 90th
Percentile: 26%
(23/90)
Elevated BP
Addressed: 65%
(15/23)
BP Percentile Not
Documented
20% (23/113)
Normal
NormalBP:
BP:74%
4%
(67/90)
Elevated BP Not
Addressed: 35%
(35/13)
(8/23)
BP Not
Documented
5%(6/119)
BP >90th
Percentile 39%
(9/23)
Elevated BP
Addressed: 33%
(3/9)
Normal BP: 61%
(14/23)
Elevated BP Not
Addressed: 66%
(6/9)
PDSA I-III:
Education and reinforcement for providers
 Powerpoint presentation
on BP guidelines given to
all providers
 Reminder notes on the
computers
 Emails and report card
PDSA II: Reminder Notes
PDSA III: Many e-mail reminders to F6
….and report card
Progress over time in BP documentation
and recognition of abnormal values
100%
90%
80%
BP Measurement
70%
Percent of total
Documentation of BP%
60%
Abnormal BP recognized
50%
40%
Documentation of BP% for
Rechecked BPs
30%
Recognition that Recheck BP
was abnormal
20%
10%
• Education
• Post-it reminders
• E-mails
• Report card
0%
PRE (n=119)
MID (n=60)
Time
FINAL (n=77)
To have > 80% of providers acknowledge and
categorize staging of elevated BP
High BP: Now what?...
Recommendations from Nephrology
 Time Course to Recheck
Abnormal BPs (if
asymptomatic)
 First Detection –
Return within 2 weeks
 Second Detection –
Return within 2 weeks
 Third Detection – Dx of
preHTN/HTN, proceed
with appropriate work up
PDSA IV: Rechecking Abnormal BPs:
A. BP Only Visit or B. School Nurse Note
MA Candida Rodriguez
What happened to pts with high BP?
BP ≥ 90th percentile:
6 /77 (~8%)
Two repeat BPs?
Yes: 3/6
2/3 repeat at clinic. 1/3 check by home RN
All confirmed. Stage I
• 2 Seen by renal + full work-up
- 1 Work-up negative. Started on
amlodipine
- 1 RUS abnormal. Close follow-up planned
• 1 partial work-up (labs but no RUS/echo)
- Referred to renal but
no appt scheduled
No: 3/6
• 1 did not return for re-check
• 2 school RN form given and not
returned
Barriers
 Dynamaps tend to run high, requiring frequent re-
checks
 Already trialing manual BP with one MA
 Planning to purchase stethoscopes
 Requires additional education and training
 Currently have to exit and re-enter note to document
re-check BP %ile using F6
 Plan to upgrade Eclypsis to automatically calculate
AND record BP %ile
 Only 50% completion rate for BP repeats once high
value identified
Spread to other ACN sites
 HTN
management
order set
 BP-only visit
 School nurse BP
check form
Change Package: Spreading HTN Management
Algorithm and Eclypsis Order-set
 If Elevate BP (confirmed on 3 separate visits)
 Pre HTN (without comorbid conditions)
 Counsel about life-style changes
 Check UA
 Refer to Renal 3-6 months
 Pre-HTN (with comorbid conditions)
 Check UA
 Refer to Renal 2-3 months
 Stage I HTN
 Check UA, Renal Sonogram, Chem 10, ECHO, TSH
 Refer to Renal in 1-2 Months
 Stage II HTN
 Page Renal 87111
Does Screening Matter?
(Matthew Thompson et al. Pediatrics 2013)
 STUDY QUESTION: Does screening for HTN in children and adolescents
reduce adverse cardiovascular outcomes in adults?
 STUDY DESIGN: Systematic review of trials and controlled observational
studies in asymptomatic children and adolescents on the effectiveness and
harms of screening and treatment, as well as accuracy of blood pressure
measurement.
 RESULTS: No studies evaluated the effects of screening for HTN on
health outcomes. Sensitivities and specificities of child hypertension for
the later presence of adult hypertension were wide ranging (0–0.63 and
0.77–1.0, respectively). Associations between child HTN and carotid intima
media thickening and proteinuria in young adults were inconsistent.
 CONCLUSIONS: There is no direct evidence that screening for
hypertension in children and adolescents reduces adverse cardiovascular
outcomes in adults.
Resources
 1. Falkner B, et al. Blood Pressure Variability and Classification of Prehypertension and
Hypertension in Adolescence. Pediatrics 2008;122:238-242
 2. Berenson GS, et al. Association between multiple cardiovascular risk factors and
atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med 1998;
338:1650-1656
 3. MacMahon S, et. al. Blood pressure, stroke, and coronary heart disease. Part 1,
Prolonged differenced in blood pressure: prospective observational studies for the
regression dilution bias. Lancet 1990;225:765-774
 4. Arslanian SS, et al. Systolic Blood Pressure in Childhood Predicts Hypertension and
Metabolic Syndrome Later in Life. Pediatrics 2007; 119:237-246
 5. Shapiro DJ, et al. Hypertension Screening During Ambulatory Pediatric Visits in the
United States, 2000-2009. Pediatrics 2012;130:604-610.
Thank you!!! Team 181st
Attendings
Steve Caddle
Rebecca Friedman
Melanie Gissen
Melissa Glassman
Adriana Matiz
Dodi Meyer
Kim Noble
John Rausch
Noe Romo
Minna Saslaw
Dana Sirota
And special thank you to
Dr. Robert Woroniecki & the Renal Team!
MAs
Aurora Gomez
Karina Guzman
Maribel Jimenez
Petra Ortiz
Candida Rodriguez
Residents
Edna Akoto
Serine Avagyan
Oliver Barry
Anna Gay
Andy Geneslaw
Carly Gomes
Laura Kurek
Natasha Li
Shannon Nees
Monica Prieto
Sarah Richman
Vanessa Salcedo
Emily Skoda
Zoya Treyster
Jason Winkler
Daniel Yu
Sam Zhao