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Leeds Blood Pressure Wise

Service Guide

Guidance for Blood Pressure Champions

February 2018

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Contents

Useful contacts 3

Introduction 4

- Blood pressure: The problem

- Blood pressure in Leeds

- Leeds Blood Pressure Wise

- Aims of Leeds Blood Pressure Wise

- What is high blood pressure?

- What is atrial fibrillation?

- What is One You Leeds?

Your Role 7

- Pharmacy Blood Pressure Champions: What’s my role?

- Who is eligible?

- How to use the blood pressure monitor

- Viewing, deleting and transferring measurements

- Error messages

Clinical pathway 12

- NICE guidance

- The consultation room

- How to take a blood pressure measurement

- The technique

- The measurement

- Next steps

- Payment

The IT system 15

Managing the loan of the BP monitors 19

Better Conversations 20

- What causes high blood pressure?

- What happens if I have high blood pressure?

- What is an NHS Health Check?

- Healthy lifestyle guidance

Resources 22

- Online

- Print

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Useful Contacts

If you have any questions regarding the programme, or if any issues arise

during its course, please contact:

Helen Ingle

Advanced Health Improvement Specialist

Older people, Long Term Conditions and Cancer

Email: Helen.Ingle@leeds.gov.uk

Mobile: 07712 214 852

Louise Jowett

Locality Support Co-ordinator

Primary Care Team

Email: l.jowett@nhs.net

Telephone: 0113 8435491

For issues regarding the template, please contact:

Craig Calvert

Email: craig.calvert@nhs.net

Mobile: 07984 145161

For issues regarding the IT system, please contact:

Egton Helpdesk

0845 1214040

For issues regarding evaluation / collating patient feedback, please contact:

Will Ridge

Integrated Business Intelligence Manager, Leeds City Council

Tel: 07766 142 522

Will.Ridge@Leeds.gov.uk

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Introduction

Blood pressure: the problem

• High blood pressure*See page 6 is the second biggest known global risk

factor for disease after poor diet (Global Burden of Disease 2015).

• In the UK, high blood pressure affects more than one in four adults

and is the second biggest risk factor for premature death and disability.

• High blood pressure is the largest single known risk factor for

cardiovascular disease (CVD) and related disability. It also increases

the risk of heart failure, coronary artery disease, stroke, chronic kidney

disease, peripheral arterial disease, and vascular dementia.

• Diseases caused by high blood pressure cost the NHS over £2billion

every year.

• The burden of high blood pressure is greatest among individuals from

low-income households and those living in deprived areas. People

from the most deprived areas are 30% more likely than the least-

deprived to have hypertension.

• High blood pressure rarely has noticeable symptoms, but if untreated,

it increases the risk of serious problems such as heart attacks and

strokes.

Blood pressure in Leeds Leeds has the ambition to be the best city in the UK for health and wellbeing.

Despite significant improvements in health across the city, the vision remains

the same: ‘to be a healthy and caring city for all ages, where people who are

the poorest improve their health the fastest’ (Health and Wellbeing Strategy).

There are an estimated 193,000 individuals with hypertension in Leeds; this

represents a large proportion of the Leeds population, and only 102,000 of

these people have a hypertension diagnosis, and just 82,100 of them are

currently eing managed for hypertension (West Yorkshire Hypertension

Dashboard 2016).

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Leeds Blood Pressure Wise Leeds Blood Pressure Wise, a British Heart Foundation-funded project, aims

to contribute towards the reduction of premature mortality in Leeds by

increasing the detection of undiagnosed high blood pressure.

The project will last for two years and plans to target people who may not

regularly visit the GP. The campaign hopes to provide 10,000 blood pressure

checks over the two years.

The programme will begin in January 2018 with blood pressure checks being

undertaken in the Leeds City Council workplace, initially targeting front line

staff. The workplace blood pressure checks will aim to make up 7,600 of the

10,000 checks.

The remaining 2,400 checks will be undertaken in pharmacies by pharmacy

blood pressure champions. This will involve community pharmacy blood

pressure checks at six pharmacies in some of the most deprived areas of

Leeds (LS8, 9, 10 and 13).

If a person presents with a raised blood pressure reading at the initial

appointment they will be loaned a monitor and encouraged to carry out one

weeks home blood pressure monitoring. A follow up appointment will be

arranged to discuss the week’s readings.

People that present with a raised blood pressure at the follow up will be

signposted to their GP practice. All appointment information will be inputted

onto the blood pressure wise template and shared with the person’s GP

practice.

It is hoped that Leeds Blood Pressure Wise will identify those with

undiagnosed high blood pressure and change patient behaviours, educating

patients about the links between lifestyle choices and blood pressure.

Aims of Leeds Blood Pressure Wise

As part of the bid to the British Heart Foundation we are committed to

achieving the following:

• Increase the detection of people with undiagnosed high blood pressure

in Leeds.

• Increase accessibility to blood pressure testing in wider community

settings particularly within deprived Leeds and 'hard to reach' groups

where the prevalence of CVD and strokes are higher.

• Increase support for self-management and promote routine blood

pressure monitoring.

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• Work collaboratively with partners and the British Heart Foundation to

add to the evidence base on detection of high blood pressure

especially in communities of greatest need.

• Signposting eligible people into NHS Health Checks and wider services

including One You Leeds*See below.

* What is high blood pressure? High blood pressure, or hypertension, is persistently raised arterial blood

pressure.

Blood pressure is recorded with two numbers. The systolic pressure (higher

number) is the force at which your heart pumps blood around your body. The

diastolic pressure (lower number) is the resistance to the blood flow in the

blood vessels. They're both measured in millimetres of mercury (mmHg).

What is atrial fibrillation?

Atrial fibrillation (AF) is an arrhythmia. It results from irregular, disorganised

electrical activity in the atria, leading to an irregular ventricular rhythm. The

ventricular rate of untreated AF often averages between 160–180 beats per

minute (although this is typically slower in older people.)

* What is One You Leeds?

One You Leeds is a free local healthy living service designed to support

Leeds residents to start and maintain a healthy lifestyle. The site can be found

at www.oneyouleeds.co.uk and contains health advice including how to eat

well, be active and maintain a healthy weight.

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Your role

Pharmacy Blood Pressure Champions: What’s my role? Your pharmacy is located within one of the most deprived areas of Leeds and

will provide an opportunistic community blood pressure programme to

increase detection of high blood pressure and reduce the burden on GP

practices. The campaign will last two years.

This service will allow the pharmacist to record blood pressure readings onto

the Leeds Blood Pressure Wise clinical template using Systm1 Mobile

Working. The use of the template on the S1 app will allow for the transfer of

data back to primary care to ensure patient records and hypertension

registers are updated.

Pharmacy staff will carry out BP monitoring and offer a preliminary diagnosis

in addition to using a ‘making every contact count’ approach to support

behaviour change, and provide information on relevant lifestyle referral

pathways and local activities through One You Leeds -

http://www.oneyouleeds.org.uk/.

Pharmacy Blood Pressure Champions will provide initial blood pressure

testing in the pharmacy. Patients that present with a raised blood pressure at

the initial appointment will be provided with validated BP monitors to carry out

home blood pressure monitoring (HBPM) which will be performed in line with

National Institute for Health and Care Excellence (NICE) guidance.

Following HBPM individuals will return to the pharmacy for follow up and a

review of the data where they will exit the program with lifestyle advice if blood

pressure is below <140/90mmHg or be advised to see their GP for diagnosis

and management of hypertension if their average blood pressure reading is

≥135/85mmHg.

Who is eligible for Leeds Blood Pressure Wise?

To be able to use Leeds Blood Pressure Wise the patient must:

1. Be over 35

2. Have no long-term health conditions which involves an annual blood

pressure check (e.g. heart disease, diabetes)

3. Not be pregnant

4. Not have had a blood pressure check at a GP practice in the last 12

months

5. Not have been diagnosed with high blood pressure recently.

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How to use the BP monitor

For a quick demonstration of how to use the BP monitor you can watch this

video or view the instructions below: https://youtu.be/3GILnT94744

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Leeds Blood Pressure Wise Clinical Pathway

NORMAL BP

<140/90

and pulse reading normal.

RAISED BP >140-90 and normal OR irregular pulse

Repeat test after 5 minutes. If the 2nd measurement is substantially different from the first, take a 3rd measurement. Record the lower of the last 2 measurements.

SEVERE BP

>180 systolic and / or >110 diastolic

Repeat test after 5 mins.

LOW BP

<90/60

Repeat test after 5 minutes.

IRREGULAR PULSE

and normal blood pressure (if raised BP, follow ‘Raised BP’ pathway)

Repeat test after 5 minutes.

No further testing required.

Give letter.

Discuss health needs / lifestyle issues.

Provide BP / lifestyle leaflets.

Signposting to One You Leeds service.

Update and save template - client BP readings and pulse details sent back to GP.

If reading is still high, discuss home BP monitoring. Complete BPM loan form and client sign. Set date for follow up appointment. Give letter, BP monitor and home diary. Show how to use BP monitor.

Home BP monitoring by client for 7 days

After 1 week, client returns for follow-up appt. Calculate average BP readings (omit day 1). If still high (≥135/85 code as raised blood pressure if under 80 yrs or ≥ 150/95 if 80 yrs+) advise to visit GP. Give letter/s.

Update and save template - client BP readings and pulse details sent back to GP.

If still raised, Task GP to follow up patient.

If normal readings – discuss health needs / lifestyle advice and signpost to One You Leeds service.

If still severe, advise client to visit GP urgently (within 24-48 hrs if possible)

If not registered with a GP, advise client to visit A&E urgently (within 24-48 hrs if possible).

Give letter.

Provide BP leaflet.

Update and save template - client BP readings and pulse details sent back to GP.

Task GP to follow up.

If still low, ask if client has symptoms of dizziness or light-headedness.

If client HAS symptoms, advise to visit GP surgery within 3 working days for further advice and tests.

If NO symptoms, signpost to NHS Choices website for information on hypotension.

Give letter. Provide BP / lifestyle leaflets.

Signposting to One You Leeds service.

Update and save template - client BP readings and pulse details sent back to GP. Task GP to follow up.

If pulse is still irregular, advise to visit GP surgery within 3 working days for further advice and tests.

Give letter.

Provide BP / lifestyle leaflets.

Signposting to One You Leeds service.

Update and save template - client BP readings and pulse details sent back to GP.

Task GP to follow up.

Check exclusion criteria. Patient and patient’s GP identified on NHS Spine using personal information. Enter personal information on template.

Consent provided by the patient (complete paper form and tick both boxes on template).

TAKE BLOOD PRESSURE (patient must be relaxed, quiet and seated, with their arm outstretched and supported. Follow further instructions in Service Guide).

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NICE guidance on blood pressure testing and managing hypertension

https://www.nice.org.uk/guidance/cg127

The consultation room

The pharmacy / workplace must be able to provide a consultation room in

which to undertake blood pressure measurements and provide confidential

advice.

Consultation rooms must meet the following requirements:

• The client and BP champion can sit down together.

• They can talk at normal speaking volumes without being overheard by

staff or customers.

• The client can rest their arm on a table/ bench at a suitable height, (see

measuring Blood Pressure).

• The area is clearly signed as a private consultation room.

• If possible, be a quiet area.

Tip: Consider what your consultation room looks like from the patient’s

perspective. Does it look like a clean, professional and safe environment? If

you store excess stock etc. in the consultation room you may need to

consider storing this elsewhere.

How to take a blood pressure measurement

Measure the blood pressure in both arms and record both readings. Use the

arm with the highest reading if further BP measurements are needed. Input

the recorded measurements onto the S1 template.

It is essential that the blood pressure measurement taken is accurately.

Carefully follow the procedure below so that the measured blood pressure is

quality-assured and can be relied on by the person being tested and their GP.

This procedure has been compiled from British Hypertension Society

guidance xii and NICE recommendations.

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The technique

• Ensure your hands are clean.

• Ask the person being tested if they would prefer either of their arms not

to be used – for example because of previous trauma or surgery.

• The cuff should be placed two to three centimetres above the elbow

joint.

• The whole cuff should be placed directly next to the skin and clothing

above the cuff should be loose – remove arm from sleeve if necessary.

• The centre of the bladder in the cuff should be positioned over the line

of the artery. The cuffs have this marked on them.

• The arm should be supported at the level of the mid sternum (heart

level). If the arm is below heart level it can lead to an overestimation of

the systolic and diastolic pressure by about 10 mmHg. Having the arm

above heart level can lead to underestimation.

The measurement

• Measure the blood pressure in both arms and record both readings.

• If the difference in readings between arms is more than 20 mmHg

systolic or 10mmHg diastolic, the pharmacist should advise client to

visit GP for further investigation routinely.

• Use the arm with the highest reading if further BP measurements are

needed.

• Complete the recorded measurements on the S1 template.

• Repeat 3 times?

Payment

We will pay the pharmacy for the screening services offered as follows:

Initial blood pressure screening £4

Referral for accelerated hypertension at 1st appointment £15

Repeat blood pressure screening following home blood

pressure monitoring £15

Interpretation of the blood pressure results will be the responsibility of the

pharmacy / workplace blood pressure champion.

Payment will be based on the data recorded on the Systm1 template. Payment will be made on a quarterly basis.

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The IT system

Instructions for using the Blood Pressure Wise

template

Step 1: Identify / register patient • Log onto the NHS Spine using your smartcard

• Click the Register button

• Enter the patient’s name, gender and date of birth then click Search

• If the patient is found click the tick beside their name

• If the patient is not found click the Register New Patient button

• Click the Add New Address button

• Click Home

16 • Type the house number and postcode and click Find, then click OK

• Click OK on the toolbar

• Cancel the Record Referral In box (this isn’t required) and click OK to the

following dialog box

• If prompted to register another patient, click No

Completing the template

• Select Blood Pressure Wise on the left and then click the BP button to open the

template

• You can complete as much or as little of the template as necessary at each stage

(for example, on the initial appointment you may complete just the first two tabs).

Click OK at the bottom of the template to close it

• Click the Save button on the toolbar to save the information you have recorded

and close the patient record

• To re-open a patient record use the Search button on the toolbar

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Step 2:

Patient

information • Tick the

Consent

given to

share

clinical

information

with GP box

Note: if the

patient does

not give

consent

then they

cannot take

part in the program

• If appropriate tick the Consent given for observational study participation box

• Click the R button to record the patient’s ethnicity

• If the patient’s GP cannot be identified tick the box at the bottom of the template

Step 3:

Initial

appointment • Enter the appropriate BP and pulse readings

• Select the relevant option for the location where the reading took place

• The Recall button can be used to enter a diary note (e.g. to follow up the return

of the home blood pressure monitoring equipment)

18 • The Loan Equipment button should be used to record that a home blood

pressure

monitor has

been loaned to

the patient

Step 4:

Follow up

appointment • Complete

each of the

home blood

pressure

readings as

appropriate

Note: You must also record the date of each reading

• Calculate the average systolic and diastolic readings and enter into the

appropriate boxes

Step 5:

Outcome

• Enter the

outcome data

as appropriate

• Select and

send

appropriate

GP letter (if a

System One

surgery,

please use the

embedded GP

letters. If an EMIS surgery please email appropriate letter to the GP)

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Managing the loan of BP monitors

Please use the ‘Loan of Blood Pressure Monitor’ form to keep a record of patients who borrow a blood pressure monitor for home testing (example shown below): ___________________________________________________________

Loan of Digital Blood Pressure Monitor

(for home blood pressure monitoring) Name: Tel no: Address: Date: (Please indicate proof of identification provided): ……………………………… Description of equipment borrowed and serial numbers .…………………………………………………. Specified return date: ………………. Declaration I agree to the safekeeping of the equipment detailed above and to return all items on the date specified. Any loss or damage to the equipment may result in a claim for reimbursement or any reasonable costs incurred. Signed: Print name: Authorising Signature (BP Champion): Pharmacy / workplace use only I confirm that the above item(s) have been returned in a satisfactory condition.

Signed: Date:

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Better conversations

• Engage in a brief discussion about the client’s current lifestyle habits / health needs (diet, smoking, physical activity, alcohol, weight).

• Provide general advice on improving lifestyle and reducing risk factors in line with the usual advice and information provided.

• Reinforce this advice where necessary with written information (e.g. blood pressure leaflets) and/or links to online resources.

• Signpost to support services as required e.g. One You Leeds.

• Record any advice and signposting provided on the Leeds BP Wise template.

What causes high blood pressure? (NHS Choices) It's not always clear what causes high blood pressure, but certain things can increase your risk e.g. if you: •are over the age of 65 •are overweight or obese •are of African or Caribbean descent •have a relative with high blood pressure •eat too much salt and don't eat enough fruit and vegetables •don't do enough physical activity •drink too much alcohol or coffee (or other caffeine-based drinks) •smoke •don't get much sleep or have disturbed sleep Making healthy lifestyle changes can help reduce your chances of getting high blood pressure and help lower your blood pressure if it's already high.

What happens if I have high blood pressure? (NHS Choices) If your blood pressure is found to be too high or too low, your GP or the healthcare professional performing the test can advise you about ways to control it. This may involve:

• adopting a healthy, balanced diet and restricting your salt intake

• being regularly physically active

• cutting down on alcohol

• losing weight

• stopping smoking

• taking medication, such as angiotensin-converting enzyme (ACE) inhibitors or calcium channel blockers

In some cases, you may be referred to a doctor such as a cardiologist (heart specialist) to discuss treatment options.

What is a NHS Health Check? (NHS Choices)

21 If you are between 40 and 74, every 5 years you will be invited to have an NHS Health Check. This is a different and more comprehensive check-up than our test today. The health check helps you to measure your risk of developing diabetes, heart and kidney disease and stroke and to prevent or delay the onset of these conditions. Make sure you book your appointment when you receive the invitation.

Healthy lifestyle guidance

Salt Salt raises your blood pressure. The more salt you eat, the higher your blood pressure. Aim to eat less than 6g of salt a day. A lot of foods we buy in supermarkets have added salt so check the labels and use the BHF reading food labels guide to help you. Eating a low-fat diet that includes lots of fibre (for example, wholegrain rice, bread and pasta) and plenty of fruit and vegetables has been proven to help lower blood pressure. Aim to eat five portions of fruit and vegetables every day.

Caffeine Drinking more than four cups of caffeine-rich drinks a day may increase your blood pressure. If you are a big fan of coffee, tea, cola and some energy drinks, consider cutting down.

Alcohol Regularly drinking alcohol above what the NHS recommends will raise your blood pressure over time. Knowing your units will help you stay in control of your drinking. For more information on drinking less and alcohol visit: http://www.oneyouleeds.org.uk/pages/information-on-alcohol

Physical Activity Being physically active and taking regular exercise lowers blood pressure by keeping your heart and blood vessels in good condition. Regular exercise can also help you to lose weight, which will also help lower your blood pressure, and is also good for your mental health. Adults should aim to build up to doing at least 150 minutes of moderate-intensity aerobic activity (e.g. cycling or brisk walking) every week. For it to count, the activity should make you feel warm and slightly out of breath. Physical activity can include anything from walking to gardening, housework to sport. Get more ideas on being active in your local area from http://www.oneyouleeds.org.uk/pages/information-on-physical-activity.

Weight Being overweight forces your heart to work harder to pump blood around your body, which can raise your blood pressure. If you do need to lose some weight, it is worth remembering that just losing a few pounds can make a big difference to your blood pressure and overall health. Get more information on

22 weight management and ideas to support you or your patients at http://www.oneyouleeds.org.uk/pages/information-on-weight-management

Smoking Smoking doesn't directly cause high blood pressure but it puts you at much higher risk of a heart attack and stroke. Smoking, like high blood pressure, will cause your arteries to narrow. If you smoke and have high blood pressure, your arteries will narrow much more quickly and your risk of a heart or lung disease in the future is dramatically increased. Get help to stop smoking as you are more likely to quit. http://www.oneyouleeds.org.uk/pages/information-on-stopping-smoking

Resources

Online British Heart Foundation: www.bhf.org.uk NHS Choices: http://www.nhs.uk/Conditions/Blood-pressure-(high)/Pages/Introduction.aspx#definition NHS One You:

https://www.nhs.uk/oneyou/#

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Print

Resource Details Where can I obtain this from?

BHF Blood Pressure

Booklet

This booklet is for people who want

to know more about high blood

pressure. It explains what high

blood pressure is, why it is so

important to control high blood

pressure, what you can do to help

and what medicines are used to

treat it.

Order, Download and Print at

https://www.bhf.org.uk/publicati

ons/heart-conditions/blood-

pressure

Order via the BHF contact

number: 0870 600 6566

BHF Atrial

Fibrillation

Designed for people with atrial

fibrillation, useful also for family and

friends. The booklet describes the

heart's normal rhythm, what atrial

fibrillation is, diagnosis,

complications, and different types of

treatment.

Order, Download and Print at

https://www.bhf.org.uk/publicati

ons/heart-conditions/atrial-

fibrillation

Order via the BHF contact

number: 0870 600 6566

BHF 10 minutes to

change your life –

High Blood Pressure

This simple guide is for people who have been told they have high blood pressure, or are at risk of getting it. It explains what high blood pressure is, what can cause it, and what you can do to lower it.

Order, Download and Print at

https://www.bhf.org.uk/publicati

ons/heart-conditions/10-

minutes-to-change-your-life---

high-blood-pressure

Order via the BHF contact

number: 0870 600 6566

BHF 10 minutes to

change your life –

Lower cholesterol

A quick guide for people with high cholesterol. This booklet explains why it's important to lower your cholesterol and makes simple suggestions for keeping your heart healthy.

Order, Download and Print at

https://www.bhf.org.uk/publicati

ons/heart-conditions/10-

minutes-to-change-your-life---

lowering-cholesterol

Order via the BHF contact

number: 0870 600 6566

BHF 10 minutes to

change your life –

A simple guide to how alcohol can affect your heart. It comes with a

Order, Download and Print at

https://www.bhf.org.uk/publicati

24

Call time on alcohol

challenge chart to help you track how much you're drinking, and set a goal to cut down if you need to.

ons/healthy-eating-and-

drinking/10-minutes-to-change-

your-life---call-time-on-alcohol

Order via the BHF contact

number: 0870 600 6566

BHF 10 minutes to

change your life –

Time to quit

A quick guide explaining why it's important to quit smoking. It talks about different ways to quit and how to find people who can help you. It comes with a chart to help you plan how you're going to quit, and tick off your smoking-free days.

https://www.bhf.org.uk/publicati

ons/smoking/10-minutes-to-

change-your-life---time-to-quit

Order via the BHF contact

number: 0870 600 6566

BHF 10 minutes to

change your life –

Time to eat well

This booklet explains what to eat and what not to eat to help keep your heart healthy. It comes with a challenge chart to help you track how much fruit and veg you're eating, and what foods you're eating that are high in saturated fat and salt.

Order, Download and Print at

https://www.bhf.org.uk/publicati

ons/healthy-eating-and-

drinking/10-minutes-to-change-

your-life---time-to-eat-well

Order via the BHF contact

number: 0870 600 6566

BHF 10 minutes to

change your life –

Time to get moving

This simple guide to getting active includes information about why you should be active, and tells you what type of activity you need to do to help your heart. It comes with a challenge chart to help you track your activity over a week and set yourself a goal for the future.

Order, Download and Print at

https://www.bhf.org.uk/publicati

ons/being-active/10-minutes-to-

change-your-life--time-to-get-

moving-booklet

Order via the BHF contact

number: 0870 600 6566

BHF 10 minutes to

change your life –

Take time out

A short booklet full of ideas to help you lower your stress levels and keep your body and mind healthy. It comes with a planner to help you pinpoint likely ‘danger spots’ for stressful situations and plan in some stress-busting activities.

Order, Download and Print at

https://www.bhf.org.uk/publicati

ons/stress/10-minutes-to-

change-your-life---take-time-out