The validity of emergency department triage blood pressure measurements

Design and validation of a new scale for prehospital evaluation of stroke and large vessel occlusion

Background

Rapid recognition of acute stroke and large vessel occlusion (LVO) is essential in prehospital triage for timely reperfusion treatment.

Objective

This study aimed to develop and validate a new screening tool for both stroke and LVO in an urban Chinese population.

Methods

This study included patients with suspected stroke who were transferred to our hospital by emergency medical services between July 2017 and June 2021. The population was randomly partitioned into training (70%) and validation (30%) groups. The Staring-Hypertension-atrIal fibrillation-sPeech-weakneSs (SHIPS) scale, consisting of both clinical and medical history information, was generated based on multivariate logistic models. The predictive ability of the SHIPS scale was evaluated and compared with other scales using receiver operating characteristic (ROC) curve comparison analysis.

Results

A total of 400 patients were included in this analysis. In the training group (n = 280), the SHIPS scale showed a sensitivity of 90.4% and specificity of 60.8% in predicting stroke and a sensitivity of 75% and specificity of 61.5% in predicting LVO. In the validation group (n = 120), the SHIPS scale was not inferior to Stroke 1-2-0 (p = 0.301) in predicting stroke and was significantly better than the Cincinnati Stroke Triage Assessment Tool (C-STAT; formerly CPSSS) and the Prehospital Acute Stroke Severity scale (PASS) (all p < 0.05) in predicting LVO. In addition, including medical history in the scale was significantly better than using symptoms alone in detecting stroke (training group, 0.853 versus 0.818; validation group, 0.814 versus 0.764) and LVO (training group, 0.748 versus 0.722; validation group, 0.825 versus 0.778).

Conclusion

The SHIPS scale may serve as a superior screening tool for stroke and LVO identification in prehospital triage. Including medical history in the SHIPS scale improves the predictive value compared with clinical symptoms alone.

Association of Elevated Blood Pressure in the Emergency Department With Chronically Elevated Blood Pressure

Background Emergency department (ED) visits for hypertension are rising, but the importance of elevated blood pressure (BP) measured during the ED visit is controversial. We evaluated the relationship between ED BP and mean BP over the subsequent year. Methods and Results We performed a retrospective cohort study from January 1, 2010 to December 31, 2013 of 8105 adult patients who made 1 visit to an academic medical center ED with ≥2 ED BPs and ≥2 BPs measured in the subsequent year. The primary exposure was lowest ED systolic BP. The primary outcome was mean systolic BP ≥140 mm Hg over the year following the index ED visit. Diastolic BP was examined as a secondary exposure and outcome. Multiple logistic regression was performed adjusting for several covariates, with interaction terms for hypertension diagnosis, ED disposition, pain-related ED chief complaint, and sex. Patients whose lowest ED systolic BP was 140 to 159 mm Hg had an adjusted odds ratio of having a mean SBP ≥140 mm Hg in the subsequent year of 10.9 (95% CI, 7.6-15.6). Patients without diagnosed hypertension and ED BP 140/90 to 159/99 mm Hg were more likely to have elevated BP in the following year. Hospitalization increased the likelihood of persistently elevated systolic BP but not diastolic BP. There was no effect modification by pain-related ED complaint. Conclusions When ED BP is consistently elevated, BP is highly likely to remain elevated in the subsequent year, regardless of pain, and particularly among patients without diagnosed hypertension. Further research is needed to determine the optimal management of elevated ED BP.

Sources of inaccuracy in the measurement of adult patients' resting blood pressure in clinical settings: a systematic review

BACKGROUND

To interpret blood pressure (BP) data appropriately, healthcare providers need to be knowledgeable of the factors that can potentially impact the accuracy of BP measurement and contribute to variability between measurements.

METHODS

A systematic review of studies quantifying BP measurement inaccuracy. Medline and CINAHL databases were searched for empirical articles and systematic reviews published up to June 2015. Empirical articles were included if they reported a study that was relevant to the measurement of adult patients' resting BP at the upper arm in a clinical setting (e.g. ward or office); identified a specific source of inaccuracy; and quantified its effect. Reference lists and reviews were searched for additional articles.

RESULTS

A total of 328 empirical studies were included. They investigated 29 potential sources of inaccuracy, categorized as relating to the patient, device, procedure or observer. Significant directional effects were found for 27; however, for some, the effects were inconsistent in direction. Compared with true resting BP, significant effects of individual sources ranged from -23.6 to +33 mmHg SBP and -14 to +23 mmHg DBP.

CONCLUSION

A single BP value outside the expected range should be interpreted with caution and not taken as a definitive indicator of clinical deterioration. Where a measurement is abnormally high or low, further measurements should be taken and averaged. Wherever possible, BP values should be recorded graphically within ranges. This may reduce the impact of sources of inaccuracy and reduce the scope for misinterpretations based on small, likely erroneous or misleading, changes.

Hypertension in the Emergency Department

Hypertension is the leading risk factor for the global burden of disease, yet more than 20% of adults with hypertension are unaware of their condition. Underlying hypertension affects over 25% emergency department attendees, and the condition is more commonly encountered in emergency departments than in primary care settings. Emergency departments are strategically well placed to fulfill the important public health goal of screening for hypertension, yet less than 30% of patients with mild to severe hypertension are referred for follow up. In predominantly African American populations, subclinical hypertensive disease is highly prevalent in ED attendees with asymptomatic elevated blood pressure. Although medical intervention is not usually required, in select patient populations, it may be beneficial for antihypertensive medications to be started or adjusted in the emergency department, aiming for optimizing blood pressure control earlier while waiting for continuing care.

Differences in automated and manual blood pressure measurement in hospitalized psychiatric patients

Few studies have been conducted recently with noncritically ill patients evaluating commonly used automated blood pressure (BP) devices. The purpose of this study was to compare BP values obtained using a manual sphygmomanometer versus an oscillometric automated electronic BP device on an acute care psychiatry unit. A method-comparison design was used, and data were analyzed using the Bland-Altman method. Outliers were removed, resulting in 39 participants for analyses of systolic readings and 41 participants for diastolic readings. Paired t tests revealed a significant difference in manual versus automatic systolic BP readings (p < 0.05). Automated readings averaged 3.9 points higher. No significant differences in diastolic readings (p = 0.72) were found. Care must be taken in using automated or manual BP readings to make important clinical decisions. Based on these findings, a protocol was instituted in an acute care psychiatry unit indicating that BP must be measured manually for patients with medication-hold parameters for BP.

Course of untreated high blood pressure in the emergency department

Introduction

No clear understanding exists about the course of a patient's blood pressure (BP) during an emergency department (ED) visit. Prior investigations have demonstrated that BP can be reduced by removing patients from treatment areas or by placing patients supine and observing them for several hours. However, modern EDs are chaotic and noisy places where patients and their families wait for long periods in an unfamiliar environment. We sought to determine the stability of repeated BP measurements in the ED environment.

Methods

A prospective study was performed at an urban ED. Research assistants trained and certified in BP measurement obtained sequential manual BPs and heart rates on a convenience sample of 76 patients, beginning with the patient arrival in the ED. Patients were observed through their stay for up to 2 hours, and BP was measured at 10-minute intervals. Data analysis with SAS PROC MIXED (SAS Institute, Cary, North Carolina) for regression models with correlated data determined the shape of the curve as BP changed over time. Patients were grouped on the basis of their presenting BP as normal (less than 140/90), elevated (140–160/90–100), or severely elevated (greater than 160/100) for the regression analysis.

Results

A statistically significant downward trend in systolic and diastolic BP was observed only for those patients presenting with severely elevated BPs (ie, greater than 160/100).

Conclusion

We demonstrate a statistically significant decline in systolic and diastolic BP over time spent in the ED only for patients with severely elevated presenting BPs.

Severe acute hypertension among inpatients admitted from the emergency department

BACKGROUND

Hospitalists often treat patients with severe acute hypertension (AH) presenting to the hospital. Little is known about the epidemiology of this syndrome.

OBJECTIVE

To examine the prevalence of severe AH in patients admitted through the emergency department (ED) and its associated outcomes.

DESIGN

A cohort study using retrospectively collected vital signs and other clinical data.

PATIENTS

A total of 1,290,804 adults admitted between 2005 and 2007.

SETTING

One hundred fourteen acute-care hospitals.

MEASUREMENTS

Severe AH was defined as at least 1 systolic blood pressure (SBP) >180 mmHg. We used multivariable regression to estimate AH-attributable in-hospital mortality, need for mechanical ventilation (MV), and length of stay (LOS).

RESULTS

Severe AH occurred in 178,131 (13.8%) patients. Disease categories with the highest prevalence were nervous (29.0%), circulatory (16.0%), endocrine (14.7%), and kidney/urinary (13.5%). The overall in-hospital mortality was 3.6%. The relationship between severe AH strata and mortality was graded for nervous system diseases; mortality rates for each 10 mmHg increase in SBP from 180 to >220 mmHg were 6.5%, 8.1%, 9.9%, 12.0%, and 19.7%, respectively (P < 0.0001). The relationship between severe AH strata and need for MV was graded in the most pronounced way in respiratory and circulatory conditions (P < 0.0001). The relationship between severe AH strata and LOS was graded in most disease categories (P < 0.0001).

CONCLUSIONS

Severe AH appears common and its prevalence varies by underlying clinical condition. Severe AH is associated with excess in-hospital mortality for patients with nervous system diseases and, for most disease categories, prolongs hospitalization.

Agreement between emergency medical services and expert blood pressure measurements

BACKGROUND

Emergency Medical Services (EMS)-measured blood pressures (BPs) are utilized for administering medications in the field and for triage decisions. Retrospective work has demonstrated poor agreement between EMS and Emergency Department (ED) BP but has lacked a valid, reliable reference standard.

STUDY OBJECTIVES

To compare EMS BP measurements with those of trained research assistants (RA) and observe measurement technique for sources of error.

METHODS

A prospective study was performed with a large urban EMS. BP measurements were made by RA within 5 min of patients presenting to the ED. EMS personnel were asked about technique. EMS personnel were then observed while RA simultaneously measured BP. Analysis was performed using methods outlined by Bland and Altman.

RESULTS

There were 100 patients enrolled for each phase. In the first phase, the mean difference in systolic BP was -3.8 ± 18.6 mm Hg (95% confidence interval [CI] -8.3 to 0.59), and the mean difference in diastolic BP was 0.42 ± 13.8 mm Hg (95% CI -3.3 to 4.1). In the second phase, the mean difference in systolic BP was -4.6 ± 10.1 mm Hg (95% CI -6.6 to -2.6) and the mean difference in diastolic BP was -3.6 ± 10.6 mm Hg (95% CI -3.6 to -0.2). EMS personnel failed to properly place the cuff or deflate it 2-3 mm Hg/s in over 90% of the readings. They failed to properly inflate the cuff in 74% of the patients, and failed to properly place the stethoscope in 40%. EMS personnel demonstrated a significant preference for the terminal digit of "0" (p < 0.0001).

CONCLUSIONS

EMS and expert BP measurements showed smaller discrepancies than those previously noted, especially with simultaneous measurements. However, EMS demonstrated poor adherence to American Heart Association recommendations for measuring BP. EMS also showed terminal digit preference.

The inaccuracy of automatic devices taking postural measurements in the emergency department

Automatic devices are used to take postural blood pressures in the emergency department despite research proving their inaccuracy in taking single blood pressures. This study assessed the accuracy of an automatic device compared with a manual aneroid reference standard for determining orthostatic hypotension and postural drops at triage. Supine and standing blood pressures were taken with an automatic and a manual device in a sequential and random order, and postural drops were calculated. The manual device indicated 10/150 emergency department patients had orthostatic hypotension (7%) and the automatic device detected this with a sensitivity of 30% and a specificity of 91%. The automatic-manual differences were clinically significant in 13% of systolic drops and 37% of diastolic drops. Findings suggest that automatic devices cannot reliably detect or rule out orthostatic hypotension, indicating that triage nurses need to use manual devices to take accurate postural blood pressures for optimal patient care.

[High blood pressure in the emergency department: epidemiology and evaluation of a dedicated consultation]

OBJECTIVES

The Arterial High blood pressure represents a consultation on 5 in general medicine. The main objective of our study was to estimate patients' proportion appearing at emergency department (ED) with a high Blood pressure and to demonstrate that it is possible to detect the patients at risk of essential and secondary hypertension as well as their cardiovascular risk there.

METHODS

Non-interventional forward-looking Study led over 6 weeks. After measure of the vital parameters in the reception of ED, the patients were included if the Systolic Blood Pressure (SBP) was ≥ 140 mmHg and\or Diastolic Blood Pressure (DBP) ≥ 90 mmHg. A control of Blood Pressure (BP) was made at least 40 minutes after the inclusion. If the Arterial High blood pressure persisted (BP ≥ 140/90 mmHg and age < 30 years or BP ≥ 180/110 mmHg after 30 years), the patients had to see again a cardiologist of the hospital in 7 days because they were considered as at high cardiovascular risk.

RESULTS

A high initial BP was discovered to 582 (8,7 %) 6685 patients having consulted in ED during the period of the study. 64 % of them (n = 372) had a persistent Arterial High Blood pressure after 40 minutes. 27 patients, defined at high cardiovascular risk had a proposition of consultation of cardiology, appeared 11 to it. 4 secondary hypertension was discovered.

CONCLUSION

During the period of study, 582 patients presented a High BP. To 64 % of those who had a control of BP this imbalance was confirmed. The patients (n=27) presenting a high cardiovascular risk had a proposition of fast consultation. This one allowed discovering 4 secondary hypertension. There is thus a utility to estimate the BP in a systematic way at Emergency Department.

Out-of-hospital characteristics and care of patients with severe sepsis: a cohort study

PURPOSE

Early recognition and treatment in severe sepsis improve outcomes. However, out-of-hospital patient characteristics and emergency medical services (EMS) care in severe sepsis is understudied. Our goals were to describe out-of-hospital characteristics and EMS care in patients with severe sepsis and to evaluate associations between out-of-hospital characteristics and severity of organ dysfunction in the emergency department (ED).

MATERIALS AND METHODS

We performed a secondary data analysis of existing data from patients with severe sepsis transported by EMS to an academic medical center. We constructed multivariable linear regression models to determine if out-of-hospital factors are associated with serum lactate and sequential organ failure assessment (SOFA) in the ED.

RESULTS

Two hundred sixteen patients with severe sepsis arrived by EMS. Median serum lactate in the ED was 3.0 mmol/L (interquartile range, 2.0-5.0) and median SOFA score was 4 (interquartile range, 2-6). Sixty-three percent (135) of patients were transported by advanced life support providers and 30% (62) received intravenous fluid. Lower out-of-hospital Glasgow Coma Scale score was independently associated with elevated serum lactate (P < .01). Out-of-hospital hypotension, greater respiratory rate, and lower Glasgow Coma Scale score were associated with greater SOFA (P < .01).

CONCLUSIONS

Out-of-hospital fluid resuscitation occurred in less than one third of patients with severe sepsis, and routinely measured out-of-hospital variables were associated with greater serum lactate and SOFA in the ED.

Provider self-report and practice: reassessment and referral of emergency department patients with elevated blood pressure

BACKGROUND

We attempted to identify patient factors associated with blood pressure (BP) reassessment and to compare health-care provider self-reported reassessment and referral to actual practice in an emergency department (ED) setting.

METHODS

Provider reassessment and referral practices were determined through systematic review of 1,250 medical records at five EDs. Medical records were included if patients were > or =18 years, nonpregnant, presented with a systolic (SBP) > or =140 or diastolic BP (DBP) > or =90 mm Hg, and discharged. A separate questionnaire obtained self-reported practice patterns of health-care providers. Multivariate logistic regression identified factors associated with patient BP reassessment and referral.

RESULTS

Of 1,250 patients, only 57% underwent BP reassessment and 9% received a referral for outpatient management. The most significant independent variables related to a reassessment were as follows: treatment of elevated BP in the ED (odds ratio (OR): 6.05; 95% confidence interval (CI): 1.80-20.31), chest pain (OR: 3.90; 95% CI: 2.37-6.42), and presence of an ED reassessment protocol (OR: 2.49; 95% CI: 1.77-3.50). The most significant factors associated with a referral included treatment of elevated BP in the ED (OR: 5.55; 95% CI: 2.72-11.32), presence of a reassessment protocol (OR: 2.58; 95% CI: 1.32-5.05), and a BP reassessment (OR: 2.56; 95% CI: 1.34-4.89). For self-reported practice patterns, 379 (72%) health-care providers completed questionnaires. Providers consistently overestimated their referral practices, yet the mean referral threshold values reported (SBP, 150 mm Hg; DBP, 93 mm Hg) were lower than the mean BP values of patients who actually received a directed referral (SBP, 170 mm Hg; DBP, 97 mm Hg, P < 0.0001).

CONCLUSIONS

Reassessment and referral of discharged ED patients with elevated BP was infrequent and health-care providers overestimate their reassessment and referral efforts.

A survey of first year student nurses' experiences of learning blood pressure measurement

Blood pressure (BP) measurement is an important clinical nursing skill. Informal evaluation triggered concerns about first year student nurses' opportunities to practise it. Therefore 447 first year pre-registration nursing students completed evaluative questionnaires following two 6-week clinical placements. The data were analysed using SPSS v.13 for analysis; open comments were analysed thematically. A third of the respondents (n=137) had pre-course experience in measuring BP. Ninety-five percent (n=425) attended the university skills laboratory session. Only 36% (n=158) of students measured BP using both electronic and manual equipment in both placements and 6% (n=27) did not practise this skill in either placement. Students undergoing non-hospital placements reported fewer practice opportunities. A large number of students reported never having been supervised while measuring BP; they were more likely to be supervised while measuring BP manually than electronically. Students' self-confidence in BP measurement increased over the first year but larger number of students were confident in electronic BP. To conclude, experiences of learning BP measurement varied in terms of opportunities to practise, equipment used, supervision levels and self-confidence. Students' experiences of learning other clinical skills may also differ, which has implications for healthcare education generally.

Recognizing asymptomatic elevated blood pressure in ED patients: how good (bad) are we?

OBJECTIVE

This study was conducted to determine if emergency medicine (EM) physicians recognize emergency department (ED) patients with asymptomatic elevated blood pressure (AEBP) by diagnosis, treatment, or referral. The study also evaluated whether differences exist in identification of AEBP based on patient age, sex, race, or insurance status.

METHODS

A retrospective chart review of all adult patients presenting to a tertiary care teaching hospital ED between April 1, 2004, and June 30, 2004, was performed. Patients were included if documented blood pressure(s) were 140/90 mm Hg or higher. Exclusion criteria included age younger than 18 years or older than 89 years, history of hypertension, admission, condition clearly defined by a hypertensive state, or blood pressure lower than 140/90 mm Hg.

RESULTS

A total of 9805 charts were reviewed; 1574 (16%) patients met inclusion criteria. The average age of our study patient was 38 +/- 14 years; 51% were women and 71.8% were African American. Only 112 patients with AEBP (7%) received attention for their elevated blood pressure (ie, diagnosis, treatment, medication prescription, and/or referral). There was no statistically significant difference between patients identified with AEBP and those not recognized by ED physicians by patient age, sex, race, or insurance status.

CONCLUSIONS

Emergency department physicians recognize, treat, and/or refer only a small percentage of ED patients with AEBP. No difference in identification, treatment, or referral exists based on patient age, sex, race, or insurance status.

Hypertensive emergency and severe hypertension: what to treat, who to treat, and how to treat

Remember to treat patients, not numbers. Use fast acting shortterm medicines only when convincing evidence of rapidly evolving end-organ damage is present. For all patients, emergent or asymptomatic, the treatment goal is long-term control of hypertension. Potent IV agents for the im-mediate control of elevated blood pressure need to be used cautiously,bearing in mind both the side effects and the hazards of overly rapid control of hypertension. Conventional oral medication regimens demonstrated to modify the risks of chronic hypertension should be used whenever possible and as early as is practical to promote gradual control of hypertension. Whenever a patient presents for the evaluation of severe hypertension in an emergent setting, take the opportunity to encourage appropriate ongoing follow-up; after all, hypertension is not a single episode, it is an ongoing threat to good health.

Can wrist blood pressure oscillometer be used for triage in an adult emergency department?

STUDY OBJECTIVE

We compare the performance of a wrist blood pressure oscillometer with the mercury standard in the triage process of an emergency department (ED) and evaluate the impact of wrist blood pressure measurement on triage decision.

METHODS

Blood pressure was successively measured with the standard mercury sphygmomanometer and with the OMRON-RX-I wrist oscillometer in a convenience sample of 2,493 adult patients presenting to the ED with non-life-threatening emergencies. Wrist and mercury measures were compared using criteria of the Association for the Advancement of Medical Instrumentation (AAMI) and the British Hypertension Society (BHS). The impact on triage decisions was evaluated by estimating the rate of changes in triage decisions attributable to blood pressure results obtained with the wrist device.

RESULTS

Wrist oscillometer failed to meet the minimal requirements for recommendation by underestimating diastolic and systolic blood pressure. Mean (+/-SD) differences between mercury and wrist devices were 8.0 mm Hg (+/-14.7) for systolic and 4.2 mm Hg (+/-12.0) for diastolic measures. The cumulative percentage of blood pressure readings within 5, 10, and 15 mm Hg of the mercury standard was 32%, 58%, and 72% for systolic, and 40%, 67%, and 83% for diastolic measures, respectively. Using the wrist device would have erroneously influenced the triage decision in 7.6% of the situations. The acuity level would have been overestimated in 2.2% and underestimated in 5.4% of the triage situations.

CONCLUSION

The performance of the OMRON-RX-I wrist oscillometer does not fulfill the minimum criteria of AAMI and BHS compared with mercury standard in the ED triage setting.