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

Abstract

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 18 years, nonpregnant, presented with a systolic (SBP) 140 or diastolic BP (DBP) 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. © 2009 American Journal of Hypertension, Ltd.