Measuring Blood Pressure in Primary Care for Accurate Diagnosis and Decision Making: Implementing Evidence-based Protocols Across a Health System

Authors

Gertrude W. Manchester, University of Massachusetts Medical SchoolFollow
Deirdre C. Donahue, MCPHS University School of Nursing, Worcester, MAFollow
Catarina I. Kiefe, University of Massachusetts Medical SchoolFollow
Lori Pelletier, University of Connecticut School of Medicine, Connecticut Children’s, Hartford, CTFollow
Marie A. Sosa, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami FLFollow
Sheri A. Keitz, Lahey Hospital & Medical CenterFollow

Abstract

Abstract

Background: Evidence-based blood pressure (BP) measurement is required for optimal clinical decision-making while improper measurement risks daily diagnostic and therapeutic errors.

Objective: To implement and sustain an evidence-based BP measurement protocol without extra resources and disseminate the protocol across a primary care network.

Design, Setting, and Participants: A Plan-Do-Study-Act (PDSA) framework for quality improvement was used to design a standardized BP measurement protocol including a 5-minute rest period only for patients with persistently elevated blood pressure. The protocol was developed using Goldratt’s Theory of Constraints and Layers of Resistance to ensure multidisciplinary buy-in and was implemented in 3 groups of primary care clinics. The protocol was developed in Group 1 with high leadership engagement and disseminated to Group 2 (self-selected clinics) and Group 3 (the remainder of the network). Participants included all primary care patients ≥18 years seen during the measurement period.

Measurements: BP readings and compliance with elements of the protocol.

Results: Clinic engagement within Group 1 was high with increase in protocol adherence from 30% to >90% for measurement of 2^nd BP and from 21% to approximately 40% for the 3^rd BP. The number of patients classified as “in control” with BP goal <140/90 increased by 10%. Protocols were implemented and sustained with high fidelity in Group#1 over 3 years and thousands of BP measurements. Protocol adherence and improvement in BP control were improved, but less so in Groups 2 and 3.

Conclusions and Relevance: A modified BP measurement protocol was actionable and accepted in a busy primary care clinic without extra resources. Implementation of the protocol was associated with a sustained 10% improvement in patients with BP <140/90, decreasing possible diagnostic and therapeutic errors. This protocol avoided the need for the 5-minute waiting period in approximately 80% of patients, while focusing the scarce resources of time and space on those patients for whom the full blood pressure measurement protocol might change clinical decision-making. Dissemination of the protocol across the wider primary care network was more variable depending on local processes and leadership engagement.

Recommended Citation

Manchester, Gertrude W.; Donahue, Deirdre C.; Kiefe, Catarina I.; Pelletier, Lori; Sosa, Marie A.; and Keitz, Sheri A. (2023) "Measuring Blood Pressure in Primary Care for Accurate Diagnosis and Decision Making: Implementing Evidence-based Protocols Across a Health System," The Lahey Journal: Vol. 1: Iss. 1, Article 4.
DOI: https://doi.org/10.62081/2995-2115.1001
Available at: https://journal.lahey.org/tlj/vol1/iss1/4