Registered Nurse’s Role in Implementing Evidence-Based Practice using a Coach Strategy to Improve Blood Pressure Control

Purpose: The treatment of hypertension in primary care is complex. Registered nurses in a primary care clinic (PCC) in northeast Ohio aimed to improve blood pressure (BP) control through a coach intervention using quality improvement methods. In improvement science, a coach is used to support the initiative and ensure success. The PCC uses an interprofessional medical home model approach to address BP management. The medical home model includes a primary care provider, registered nurse (RN), licensed practical nurse (LPN), and medical support assistant (clerk). If medical management is required during RN visits, staffing is provided by an available medical provider or clinical pharmacist. In our clinic 60% of the PCC patients have uncontrolled BP.

Description: This quality improvement project assumed that each medical home team member functions at the highest level of their practice to support the patient in managing their hypertension. The quality improvement project added an additional strategy: a coach, who assisted the team to identify barriers to teamwork, enhance attention to patient-centered care, optimize quality improvement tools, map the PCC processes, provide relevant data retrieval for quality improvement, and facilitate PCC core team meeting for six months. The medical provider and patient guided the approach to the patient’s BP management. The team depended on the medical provider to use an algorithm for initiation or addition of anti-hypertensive medications. The LPN was coached in the use of the American Heart Association (AHA) guidelines to obtain an accurate BP readings. Both the LPN and RN provided patient education related to BP management and measurement following AHA guidelines. The clerk managed appointment scheduling, including provider and RN visits, and patients with missed or failed scheduling of appointments.

During the weekly team meeting, the coach provided team specific hypertension metrics. Team members were asked to generate and then initiate interventions that might impact their population’s BP. The provider began to write patient-specific BP medication orders for the next RN visit (usually within the same week). Nursing specific interventions included increasing patient visits for BP monitoring, medication management and review, home BP measurement education, and teach back; dispensing of blood pressure (BP) cuff at the RN or provider visit with immediate education and teach back with the RN; gifting zippered bags with the request to bring all medications and the BP cuff to future appointments; and phoning patients whose metrics indicated an out of control BP.

Evaluation/outcome: Patient BP readings above 140/90 were 30.6% at the beginning of the quality improvement program and were reduced to 20.6% after the intervention. Using a coach and an interprofessional team willing to evaluate its practice and generate team and role specific interventions was successful in improving hypertension control.