Diagnosis, treatment, and referral of hypertension in an emergency department

Risk of Intracerebral Hemorrhage after Emergency Department Discharges for Hypertension

BACKGROUND

Recent literature suggests that acute rises in blood pressure may precede intracerebral hemorrhage. We therefore hypothesized that patients discharged from the emergency department with hypertension face an increased risk of intracerebral hemorrhage in subsequent weeks.

METHODS

Using administrative claims data from California, New York, and Florida, we identified all patients discharged from the emergency department from 2005 to 2011 with a primary diagnosis of hypertension (ICD-9-CM codes 401-405). We excluded patients if they were hospitalized from the emergency department or had prior histories of cerebrovascular disease at the index visit with hypertension. We used the Mantel-Haenszel estimator for matched data to compare each patient's odds of intracerebral hemorrhage during days 8-38 after emergency department discharge to the same patient's odds during days 373-403 after discharge. This cohort-crossover design with a 1-week washout period enabled individual patients to serve as their own controls, thereby minimizing confounding bias.

RESULTS

Among the 552,569 patients discharged from the emergency department with a primary diagnosis of hypertension, 93 (.017%) were diagnosed with intracerebral hemorrhage during days 8-38 after discharge compared to 70 (.013%) during days 373-403 (odds ratio 1.33, 95% confidence interval .96-1.84). The odds of intracerebral hemorrhage were increased in certain subgroups of patients (≥60 years of age and those with secondary discharge diagnoses besides hypertension), but absolute risks were low in all subgroups.

CONCLUSIONS

Patients with emergency department discharges for hypertension do not face a substantially increased short-term risk of intracerebral hemorrhage after discharge.

Diagnosis, treatment, and referral of hypertension or prehypertension in an emergency department after an educational program: preliminary results

The authors prospectively audited 602 randomly selected charts of patients seen in an academic emergency department (ED) for prevalence of hypertension and its management after an educational program (EP) because of results found in auditing 500 charts before the EP. Blood pressure was not measured in 11 of 500 patients (2.2%) before the EP and in 1 of 602 patients (0.2%) after the EP (P < .005). Hypertension was treated in the ED in 14 of 187 patients (8%) before the EP and in 29 of 282 patients (10%) after the EP (P = not significant). Of 187 patients with hypertension before the EP, 99 (53%) were referred to a physician or clinic for follow-up of hypertension, and 281 of 282 patients (99.6%) with hypertension were referred to a physician or clinic for follow-up of hypertension after the EP (P < .001). These data show that an EP administered to the staff of an academic ED significantly increased measurement of blood pressure in the ED, significantly increased obtaining a history of hypertension and of its treatment in ED patients, and significantly increased referral of patients with hypertension to a physician or clinic for follow-up of hypertension.