Improving Acute Hypertension Management through Emergency Department Checklist

Johns Hopkins University, Baltimore MD

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Abstract

Project Summary There are about 1 billion people living with hypertension in the developing countries. This preventable risk factor accounts for over 10 million deaths and a significant morbidity related to heart attacks, strokes, and renal failures. Acute hypertensive emergency is a specific emergency condition in which a patient presents with a severely elevated blood pressure (systolic blood pressure ?180 mmHg or diastolic blood pressure ? 110 mmHg) and has evidence of major organ failure, e.g., heart, brain, lungs, or kidneys. About 1% of hypertensive patients could suffer from this condition during their lifetime. The diagnosis of Hypertensive Emergency requires careful evaluation consisting of blood chemistry tests and diagnostic imaging as well as cautious treatment to avoid harm caused by the precipitous blood pressure drop. The proportion of patients with acute severe hypertension in an emergency department could be as high as five percent. This is not an inconsequent burden especially in the developing countries where resources for treatment and physician training are limited. A US study showed that even in the developed world, only six percent of hypertensive patients in the emergency received appropriate work-up for the end-organ damage. Hence, the situation in the developing country could be much worse. The American College of Emergency Physicians (ACEP) also noted that there are no evidence-based guidelines available for treating acute severe hypertension in the ED settings. In the recent past, the implementation of a checklist in the emergency care settings across the globe showed the improvements in patient management and outcomes in specific conditions. We propose to develop and evaluate a checklist specific to emergency care of acute severe hypertension in a low-income setting. This has not been attempted in the past, and hence may result in new, practice changing knowledge. We propose a quasi-experimental, before-after, intervention study is to assess whether a checklist improves management and outcomes in patients of acute severe hypertension in an emergency department in Karachi, Pakistan. We develop a specific data capture system for information on emergency care and patient outcomes in short- and long-terms. The study may address the knowledge needs identified by ACEP such as ?what is the optimal management ?as it related to patient outcomes??