Best Practices
Primary care clinics are best suited to manage AH because medication adjustments and long-term monitoring are easier to perform and at substantially lower costs when compared with that of the ED. Rather than immediately referring a patient to the ED, clinicians should consider factors that could elevate BP, such as medication nonadherence, anxiety, acute pain, recent tobacco or caffeine use, or white coat syndrome. Staff should be well educated on proper BP measurement and instructed to repeat the reading for confirmation. Before measuring BP, allow the patient to sit quietly for 5 minutes with the feet flat on the floor and arm supported.3 Ideally, the measurement used should be the average of 3 BP readings on an automated device.11 If BP readings are high, staff should ask the patient about medication adherence and missed medication(s) should be administered.
It also is reasonable to have the patient rest quietly for up to 30 minutes because rest has been shown to reduce BP in some patients.12 The drawback to the prolonged rest strategy is the potential to cause delays in care for other patients. However, it is important to remember that wait times in the ED often are measured in hours, which causes frustration for patients referred to the ED for AH management. Before completing the office visit, the provider should recheck BP using proper technique and confirm that the patient has antihypertensive medication(s) in his/her possession; a follow-up appointment should be scheduled for no later than 1 week.
Primary care providers might be concerned about taking on additional liability and could favor ED referral, but legislation makes it difficult for EDs to defer nonemergent issues to primary care clinics. The Emergency Medical Treatment and Labor Act states that hospitals are prohibited from denying a patient care during an emergency.13 Despite evidence that AH is not an emergency, many patients continue to be referred to the ED. One-third of patients presented to the ED on their own volition and more than one-half were referred by health care personnel. This strongly suggests that both patients and health care personnel consider AH an emergency medical condition requiring immediate attention. However, patients with AH rarely are found to have any acute end-organ damage; therefore, acute treatment and extensive laboratory or diagnostic testing in the ED provides little, if any, benefit.10 The authors believe the ACEP clinical policy should be adopted into mainstream practice to help reduce health care costs and preserve ED resources for patients with true emergencies.
Another pervasive issue that could contribute to inappropriate AH referrals to the ED is the shortage of PCPs and limited same-day appointments for nonemergent conditions. In a 2017 survey, the average wait time for a PCP appointment ranged between 12 and 109 days, depending on the metropolitan area. The national average wait time conducted by this survey was 29.3 days.14 When primary care appointments are unavailable, triage staff could recommend that patients seek care in the ED. Additionally, patients might choose to seek ED care rather than wait for the next available PCP appointment. Clinic proximity to an ED could influence referral rates. In other words, medical centers or health systems with primary care clinics and ED services under one roof could experience more frequent ED referrals.
A promising strategy to help overcome the challenges of addressing AH and avoiding ED referrals is increasing patient access to and use of qualified, nonphysician providers, such as clinical pharmacists and nurse practitioners. Large health systems such as the VA and Kaiser Permanente have employed clinical pharmacist providers to reduce follow-up times for patients in primary care settings.15 Furthermore, there is substantial evidence that supports the cost-effectiveness and clinical success of pharmacist-driven hypertension clinics.16-18 Nurse-driven efforts to improve hypertension control have been successfully implemented in health systems.19 Both clinical pharmacist and nurse-managed hypertension clinics are effective solutions to manage patients with AH who might otherwise use costly ED services.For example, the average cost of a single ED visit is $740 to $3,437.20 In comparison, a 2010 report from the Agency for Healthcare Research and Quality showed the average annual cost of managing hypertension in ambulatory care clinics was $442 per adult, a cost considerably lower than that of the ED.21
Limitations
The retrospective and observational design of this study are inherent limitations. This study was not designed to evaluate cardiovascular outcomes after ED encounters. The sample size could have been larger if patients with BP < 180/110 mm Hg at ED triage were included; however, the 180/110 mm Hg threshold was chosen because it was the most widely agreed on BP value in the literature. This study did not capture patients who presented with AH and did not receive any acute treatment in the ED.Prescribing patterns based on provider training (eg, emergency medicine, family medicine, or internal medicine) were not tracked and might have accounted for differences in selection of diagnostic tests, laboratory ordering, and route of drug administration preference.