Enhancing Blood Pressure Measurement Workflow in Ambulatory Care

One in five patients at our academic medical center has hypertension, and only 63% have their blood pressure under control. As an institution, we aim to improve blood pressure control in our hypertensive population. Diagnosis and treatment of hypertension depends on accurate and consistent measurement of blood pressure. This measurement is often not obtained following the best practices as outlined by the American Heart Association (AHA). As of May 2018, our data displayed that 50% of our primary care practices tended to round their blood pressure readings. Additionally, during observations we noticed patients moving around the clinic room, talking during blood pressure readings, inaccurate cuff sizes, and poor patient positioning. To ensure that patients receive appropriate diagnosis and treatment of their hypertension, we set out to standardize blood pressure measurement workflow during the rooming process.

The project and its interventions were piloted in a 52-physician multispecialty practice with 30 primary care providers and 22 physicians across 10 specialties. Prior to introducing the new workflow, blood pressure measurements occurred during multiple phases of the rooming process. The AHA recommends the patient rest for 5 minutes prior to the blood pressure reading. At our primary care practice, the average amount of time patients remained in a resting state was approximately 1 minute. The following additional AHA best practices were observed during the auditing phase: patient seated comfortably, with back supported, legs uncrossed, and upper arm bared; patient’s arm supported at heart level; no talking during the procedure; the arm supported at heart level, and the use of appropriate cuff size. During a two-month time period, 100% of the medical assistants were trained on the new scripting, rooming workflow, and blood pressure technique using the AHA guidelines.

Post-intervention, we discovered an overall improvement in five of the six best practices from the AHA. Three of the six best practices were met 100% of the time (cuff size, arm supported, and patient silent during reading). The patient being seated in a proper position with back supported and legs flat on floor improved by 90%. Additionally, we had a 50% improvement of compliance in using the new scripting during the rooming process. The time the patient was at rest for five minutes prior to beginning of their blood pressure reading was not statistically significant.

Continued interventions for improving clinic workflow to accommodate AHA best practices are critical for primary care providers to make accurate diagnosis and treatment plans for their patients with hypertension. To avoid patients being falsely classified with or without hypertension, every measure to reduce poor office visit blood pressure techniques during the rooming of patients should be observed.