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 ≥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 effort