Blood Pressure ScreeningWHFHC

181st Clinic

Quality Improvement Project2010-2011 Academic Year

Annie Armstrong

Carrie Bernstein

Steve Caddle

Marina Catallozzi

Melanie Gissen

Adriana Matiz

Mary McCord

Dodi Meyer

Kim Noble

John Rausch

Minna Saslaw

Dana Sirota

Emily Eida

Dina Ferdman

Anna Gay

Carly Gomes

Faith Ihekweazu

Ben Landis

Ted Macnow

Amy Ost

Sarah Richman

Vanessa Salcedo

Nefthi Sandeep

Kim Shams

Sarah Szlam

Kristen Williams

Jason Winkler

Aurora Gomez

Carmen Nicasio

Petra Ortiz

Candida Rodriguez

David Vawdrey

Aim StatementImprove blood pressure screening anddocumentation in children 3 years and above

• Identify discrepancies between BP readings done by MAs with the automatic “Dinamap” and BP readings done by providers via auscultation

• Successfully educate 90% of providers and MAs with most recent AAP guidelines for screening, measuring, defining, and managing hypertension

• Successfully screen and document BP in 90% of children aged 3 and above during their well child visits

• Successfully document, refer, and initiate medical therapy for 90% of children with confirmed stage II hypertension

• Improve MA accuracy in recording BPs and choosing appropriate cuff size

Interventions - MAs• PDSA cycle 1 intervention:

– Redistribution of appropriate BP cuff sizes to each MA’s dinamap machine– MA education via power point presentation (Pre test: 50%/Post test: 100%)– MA’s encouraged to recheck any BP > 120/80 and document both in

flowsheet

MINI CHART REVIEW RESULTS:• 60% patients seen had BP screen• 13% had measurements >120/80, 33% of whom had pressures that were

re-checked by the MA

• PDSA cycle 2 intervention:– Recalibration of height scales – every scale was examined and adjusted.

Several scales were 1-2cm off – Post-recalibration measurements:

• 12/13 heights recorded were accurate• 1/13 height was off by 3cm (one %tile line)

Interventions - Providers• PDSA cycle 1 intervention:

– Standard NHANES BP tables were placed on wall in examination rooms next to sphygmomanometers

– Up-to-date BP calculator for boys and girls was added as favorite website in Internet Explorer in all examination rooms

– Provider powerpoint tutorial – all parameters close to 100% on post test• PDSA cycle 2 intervention:

– Tested the validity of the SmartPaste, F6, tool to determine whether it correlates accurately with the Standard Charts used to determine BP percentiles

– Emails sent to providers:– How to SmartPaste from the flowsheets– How to enter a new measured BP into the flowsheet and then use SmartPaste

a 2nd time• Better to retain the MA’s BP in addition to the newly measured BP

Results (providers) – chart reviewMeasurement phase

PDSA cycle 1

Mid Year PDSA cycle 2

% pts Screened 85 91 100 90

% pre-HTN (%repeated/%noted in AP)

24 (8/0) 20 (27/11) 23 (29/8) 5 (0/0)

% stage 1 (%repeated/%noted in AP)

10 (40/0) 9 (80/50) 11 (43/20) 17 (100/100)

% stage 2 (%repeated/%noted in AP)

2 (100/0) 5 (66/50) 3 (0/0) 17 (100/100)

* PDSA cycle 2: 70% used smartpaste in PE

0

20

40

60

80

100

120

Meas.Ph.

PDSA1 Mid Yr PDSA2

%screened

% Pre Hremeasured

% Stage Iremeasured

% Stage Iiremeasured

SmartPaste Option F6

Physician Reminder

SmartPaste accuracy• Purpose: validate accuracy of SmartPaste F6

• Methods: comparison of SmartPaste BP percentiles vs. uptodate (UTD) calculator for 21 pediatric patients (aged 3 to 17)

• Results: Discrepancies between SP and UTD BP percentiles ranged from 0 to 7 %iles• Majority of differences (either systolic or diastolic) were small

– 13/21 pts: 0 and 2 %iles– 5/21 pts: 3 to 4%iles– 3/21 pts: 5 and 7%iles

• In 2 pts the discrepancy would have lead to a difference in HTN classification – Ex. Smart paste estimated 95%ile (stage I hypertension) while UTD estimated 93 or 94%ile

(prehypertension)• Most of the larger differences (4 to 7 %iles) occurred for lower BP %iles (not clinically relevant)• Conclusions: Smart Paste BP percentiles generally correlate with the UTD BP percentiles, with

the small differences trending towards Smart Paste “overestimating” the BP percentile• As a screening tool, while this may lead to more “false positives” , it would avoid us missing any

true hypertension.

Conclusions - revisiting the AIM statement

Improve blood pressure screening anddocumentation in children 3 years and above

• Identify discrepancies between BP readings done by MAs with the automatic “Dinamap” and BP readings done by providers via auscultation

• Successfully educate 90% of providers and MAs with most recent AAP guidelines for screening, measuring, defining, and managing hypertension

• Successfully screen and document BP in 90% of children aged 3 and above during their well child visits

• Successfully document, refer, and initiate medical therapy for 90% of children with confirmed stage II hypertension

• Improve MA accuracy in recording BPs and choosing appropriate cuff size

Change Package - spreading our project to the ACN

• MA training on correct BP measurement, dinamaps for MA with appropriate cuff sizes

• Recalibration of height scales• Train MDs in SmartPaste function• Post % cutoffs for preHTN, stage 1 and stage 2

and SmartPaste signs in exam rooms