Emily Eida Dina Ferdman Anna Gay Carly Gomes Faith Ihekweazu Ben Landis Ted Macnow Amy Ost Sarah Richman Vanessa Salcedo Nefthi Sandeep Kim Shams Sarah Szlam Kristen Williams Jason Winkler Blood Pressure ScreeningWHFHC181st Clinic Annie Armstrong Carrie Bernstein Steve Caddle Marina Catallozzi Melanie Gissen Adriana Matiz Mary McCord Dodi Meyer Kim Noble John Rausch Minna Saslaw Dana Sirota Aurora Gomez Carmen Nicasio Petra Ortiz Candida Rodriguez David Vawdrey Quality Improvement Project 2010-2011 Academic Year
Aim Statement Improve blood pressure screening and documentation in children 3 years and above • Identify discrepancies between BP readings done by MAs with the automatic “Dinamap” and BP readings done by providers via auscultation • Successfully educate 90% of providers and MAs with most recent AAP guidelines for screening, measuring, defining, and managing hypertension • Successfully screen and document BP in 90% of children aged 3 and above during their well child visits • Successfully document, refer, and initiate medical therapy for 90% of children with confirmed stage II hypertension • Improve MA accuracy in recording BPs and choosing appropriate cuff size
Interventions - MAs • PDSA cycle 1 intervention: • Redistribution of appropriate BP cuff sizes to each MA’s dinamap machine • MA education via power point presentation (Pre test: 50%/Post test: 100%) • MA’s encouraged to recheck any BP > 120/80 and document both in flowsheet MINI CHART REVIEW RESULTS: • 60% patients seen had BP screen • 13% had measurements >120/80, 33% of whom had pressures that were re-checked by the MA • PDSA cycle 2 intervention: • Recalibration of height scales – every scale was examined and adjusted. Several scales were 1-2cm off • Post-recalibration measurements: • 12/13 heights recorded were accurate • 1/13 height was off by 3cm (one %tile line)
Interventions - Providers • PDSA cycle 1 intervention: • Standard NHANES BP tables were placed on wall in examination rooms next to sphygmomanometers • Up-to-date BP calculator for boys and girls was added as favorite website in Internet Explorer in all examination rooms • Provider powerpoint tutorial – all parameters close to 100% on post test • PDSA cycle 2 intervention: • Tested the validity of the SmartPaste, F6, tool to determine whether it correlates accurately with the Standard Charts used to determine BP percentiles • Emails sent to providers: • How to SmartPaste from the flowsheets • How to enter a new measured BP into the flowsheet and then use SmartPaste a 2nd time • Better to retain the MA’s BP in addition to the newly measured BP
Results (providers) – chart review * PDSA cycle 2: 70% used smartpaste in PE
SmartPaste accuracy • Purpose: validate accuracy of SmartPaste F6 • Methods: comparison of SmartPaste BP percentiles vs. uptodate (UTD) calculator for 21 pediatric patients (aged 3 to 17) • Results: Discrepancies between SP and UTD BP percentiles ranged from 0 to 7 %iles • Majority of differences (either systolic or diastolic) were small • 13/21 pts: 0 and 2 %iles • 5/21 pts: 3 to 4%iles • 3/21 pts: 5 and 7%iles • In 2 pts the discrepancy would have lead to a difference in HTN classification • Ex. Smart paste estimated 95%ile (stage I hypertension) while UTD estimated 93 or 94%ile (prehypertension) • Most of the larger differences (4 to 7 %iles) occurred for lower BP %iles (not clinically relevant) • Conclusions: Smart Paste BP percentiles generally correlate with the UTD BP percentiles, with the small differences trending towards Smart Paste “overestimating” the BP percentile • As a screening tool, while this may lead to more “false positives” , it would avoid us missing any true hypertension.
Conclusions - revisiting the AIM statement Improve blood pressure screening and documentation in children 3 years and above Identify discrepancies between BP readings done by MAs with the automatic “Dinamap” and BP readings done by providers via auscultation Successfully educate 90% of providers and MAs with most recent AAP guidelines for screening, measuring, defining, and managing hypertension Successfully screen and document BP in 90% of children aged 3 and above during their well child visits Successfully document, refer, and initiate medical therapy for 90% of children with confirmed stage II hypertension Improve MA accuracy in recording BPs and choosing appropriate cuff size
Change Package - spreading our project to the ACN • MA training on correct BP measurement, dinamaps for MA with appropriate cuff sizes • Recalibration of height scales • Train MDs in SmartPaste function • Post % cutoffs for preHTN, stage 1 and stage 2 and SmartPaste signs in exam rooms