Blood Pressure

[iish]

As ED docs, I feel like we send home patients with hypertensive urgency all the time, more or less as the standard of care as long as they have good PMD f/u, are on home antihypertensives, and can follow up reliably. I have had attendings send patients home with headaches before w/ BPs of 220s/100s without thinking twice. Naturally, I have adopted this as my practice as well, especially given the lack of any data/evidence to contradict this practice.

Now, I have gotten considerable pushback from other service regarding patients with elevated BP, urgency or non-urgency. I have had hospitalists refuse transfer of a patient to the floor for systolic over 200 and have had multiple episodes where an ambulance will not transport a patient to a nursing facility or to an OSH due to completely asyptomatic HTN w/ systolic over 200s. I don't understand why. What are they concerned about? If the patient does nto have any symptoms the chances of an emergency are slim.

The tipping point came when I was recently called out during conference on an off service for transfering a patient to another hospital that had BP 220s/120s initially. For context, the pt had been screaming and throwing a tantrum for about 1-2 hours before her BP was checked. Before I got to the bedside, the PA had written for hydralazine (not the best choice IMO), but was already given and the BP came down to 180s/90s. I watched the pt for about 40 min then rechecked the BP to make sure it was still the same and then sent her to the OSH. I did not want to engage in polypharmacy by giving her a longer acting antihypertensive either as she had held steady in the 180s/90s. When she got to the OSH her BP was back over 200 systolic and she had a HA (presumably from all the screaming) and c/o blurry vision, neither of which she had at our hospital when I had seen her. I didn't want to argue during conference so I just took it, but as per the practice patterns I've gathered in the ED in my short time as a resident, we d/c patients with that BP all the time, so what's wrong with transfer to another hospital?

Am I missing something ( which I probably feel I am )? Please regale me.

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[dotcb]

No - you are correct and the concerns of these people are nonsense. There are many factors at play in medicine besides evidence and reason, such as systems of care, usual practice, and cultural norms. What you're doing sounds completely fine. With rare exception I ignore the BP and just deal with the patient's symptoms, remotely factoring in whether or not they could be related to BP. I almost never lower BP with IV meds except in aortic dissection and acute neurologic emergencies. If I'm giving a PO med, I'm not waiting for a response to the med.

 

[xaelia]

Vital signs are symptoms of the underlying physiology. If there's an acute process related to an acute elevation in blood pressure, treat the underlying process. Any long-standing essential hypertensive physiology is appropriately treated with a gradual reduction.

Plenty of long-standing cultural fears of numbers, however. In my residency program, no one went home with SBP >200 or glucose >300. Pointless waste.

Pretty sure I've sent folks home with >240 systolic since. Had a glucose of 699 yesterday we discharged without rechecking after making the patient euvolemic. Not safe for the hospitalist on the floor, but perfectly safe for discharge home ....

 

[Birdstrike]

You're right, but...

There's a certain number with each vital sign where people just freak out. There's nothing scientific about lots of it, that's just how it is. It's just like the 104 temp in a well child with an irrelevant virus. You can talk until you're blue in the face about the "data" and all that, and how there's "nothing to do," but until you do something to make that person who is "freaking out" about it feel that you're not "blowing it of" you're just swimming up stream.

The same goes for an irrelevantly elevated BP. If everyone is freaking out about it, then do something to take a path of lesser resistance. I don't care what it is, agree to admit, give a dose of clonidine (BP) or throw an antipyretic or a "test" at the fever. Do back flip or a Jedi mind trick. Whatever.. Just don't commit to a career of banging your head against the wall.

Sure, the "science" is behind you, but when everyone in front of you is against you...Go with the flow (without compromising patient care/ethics) to make your life easier.

Choose your battles so that you've go fight left in you when some hospital CEO pressures you to do something more profoundly unethical which you can't compromise on. That's my thought on it, FWIW.

 

[deleted109597]

Artificially lowering a number by giving a single dose of a medication is bad medicine if you're not going to continue it. A single dose of clonidine can make the patient rebound.
Sure, give someone some tylenol for their fever if they feel bad, it is less likely to harm them.

If we are really ignoring the patients clinical picture and just treating the number, we should probably start amputating limbs so their weight looks better as well.

 

[TooMuchResearch]

If we treat viral pharyngitis with Decadron, amoxicillin, acetaminophen, AND Percocet, then hey, why not purposelessly drop the BP, too?

 

[The White Coat Investor]

If we treat viral pharyngitis with Decadron, amoxicillin, acetaminophen, AND Percocet, then hey, why not purposelessly drop the BP, too?

It isn't that you don't need to treat BP. It's that we were hurting people doing so. So if you must do something, do something benign (preferably using a larger cuff.)

 

[Birdstrike]

. A single dose of clonidine can make the patient rebound.

Really?

Rebound hypertension from clonidine cessation is a withdrawal syndrome from chronic therapy at moderate-higher doses (at least 6-30 days and at least 0.3-0.9 mg/day). It's not going to happen from one dose, anymore than opiate withdrawal will occur after a single dose of an opiate in opiate naive patient, or withdrawal seizures after a single dose of PO Ativan in a previously benzo naive patient.




(A very old source, but I doubt much has changed related to the science of clonidine since then)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1429594/pdf/brjclinpharm00244-0056.pdf

If we are really ignoring the patients clinical picture and just treating the number, we should probably start amputating limbs so their weight looks better as well.

Really? A homeopathic dose of an antihypertensive equals amputations for weight loss is the next necessary step?

Hey, if that's what it takes to reduce door to doctor times and improves PG scores then it's certain to become standard of care in the community setting, while those in academics continue to claim the higher ground. /end-sarcasm-font

 

[deleted109597]

Really?

Rebound hypertension from clonidine cessation is a withdrawal syndrome from chronic therapy at moderate-higher doses (at least 6-30 days and at least 0.3-0.9 mg/day). It's not going to happen from one dose, anymore than opiate withdrawal will occur after a single dose of an opiate in opiate naive patient, or withdrawal seizures after a single dose of PO Ativan in a previously benzo naive patient.




(A very old source, but I doubt much has changed related to the science of clonidine since then)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1429594/pdf/brjclinpharm00244-0056.pdf

Studies show it does in rats. No studies in humans that I can find. But hey, if you want to do it, feel free.

Really? A homeopathic dose of an antihypertensive equals amputations for weight loss is the next necessary step?

No point in picking one number to be important, while not treating the underlying problem.
If you're ok being a homeopath, then again, feel free. I would rather not potentially harm the patient. If I'm going to give a patient a drug to lower their BP, they're getting an Rx for that drug to take until they see their doctor. That's pretty rare though.

 

[Birdstrike]

If I'm going to give a patient a drug to lower their BP, they're getting an Rx for that drug to take until they see their doctor. That's pretty rare though.

Well, if you're an absolute purest, you shouldn't start a chronic daily anti-hypertensive in the ED based on one visit, one reading, either. That's marked wrong on the boards, also. And how can you say a single dose of antihypertensive is "harmful," but a script for seven doses makes it harmless from the standpoint of being academically pure and "evidence" based?

You never X-rayed an ankle you knew was only sprained?

You never, wrote an antibiotic prescription for an otitis that you weren't 100% sure wasn't viral?

You never checked a box for a lab test for the sole reason "because I know the admitting doctor will want it" (that useless CBC or chem panel) or "Joint Commission expects it" (utterly worthless 2 sets of blood cultures in the pneumonia patient without sepsis) knowing full well it won't change management or benefit patient care in any demonstrable way?

Again, I'm not advocating compromising patient care or any of the above, but I think it's worth noting how far gone we are with the forces that try to warp our decision making, from defensive medicine, to Press-Ganey, to the metrics obsession and unproven supposed "standards of care." I think trying to help a resident deal with hospital politics in a realistic way that doesn't compromise patient care is worthwhile. I'm not saying that "a dose of clonidine and out the door" is a board answer anymore than a "back flip" or Jedi mind trick" is, but the OP knows that, based on then purist stance he/she was try to take in the OP.

If you're an academic purest and always stick to that 100%, fine, but if you can't come on an anonymous internet forum and be honest about some of these realities, then really, what are we even here for?

 

[deleted109597]

Sigh. You're right. We should just bow to the whims of everyone and not hold ourselves to any real standard. That way we can't be blamed. It's the other person's fault, since they wanted whatever.

The realities of modern EDs mean that the xrays are ordered by the triage nurse/noctor/doctor whatever. When the JC makes a mandate, yes I follow it. But, two sets are no longer a core measure, so you don't need to do that.
If the admitting doctor wants it, I make them ask me for it before I order it (think octreotide, or PPI gtts, which aren't beneficial based on the literature). And yes, sometime we are stuck doing what we don't want to, but every time the nurses pull out the "policy" bull**** line, I make them show me. And since I've never actually seen it for discharged patients (sadly floor politics override common sense), I go ahead and discharge them. The ED nurses are on our side after a little explanation usually.

Just like we tell the residents, always do what is in the best interest of the patient, and you'll never be wrong. Except in the case of tPA. You're always wrong with tPA, no matter if you give it or don't.
Handly little pointer for JNC 8 here.

I probably spend more time trying to convince parents of the lack of utility for antibiotics for otitis than anything else.

 

[Birdstrike]

Sigh. You're right. We should just bow to the whims of everyone and not hold ourselves to any real standard. That way we can't be blamed. It's the other person's fault, since they wanted whatever.

The realities of modern EDs mean that the xrays are ordered by the triage nurse/noctor/doctor whatever. When the JC makes a mandate, yes I follow it. But, two sets are no longer a core measure, so you don't need to do that.
If the admitting doctor wants it, I make them ask me for it before I order it (think octreotide, or PPI gtts, which aren't beneficial based on the literature). And yes, sometime we are stuck doing what we don't want to, but every time the nurses pull out the "policy" bullcrap line, I make them show me. And since I've never actually seen it for discharged patients (sadly floor politics override common sense), I go ahead and discharge them. The ED nurses are on our side after a little explanation usually.

Just like we tell the residents, always do what is in the best interest of the patient, and you'll never be wrong. Except in the case of tPA. You're always wrong with tPA, no matter if you give it or don't.
Handly little pointer for JNC 8 here.

I probably spend more time trying to convince parents of the lack of utility for antibiotics for otitis than anything else.

I'm promise I'm not trying to be a confrontational a-s with this post. I have a wider point I'm getting at and I just want to get this right, so please correct me if I'm misunderstanding:

For many years you ordered blood cultures for all admitted pneumonias knowing it was wrong (carried cost with no benefit and could have false positives negatively altering patient care) but you no longer do?

You currently allow orders to be placed in triage, knowing many of them will be wrong (inflate healthcare costs, lead to unnecessary radiation, lead to more testing to follow up irrelevant incidentals)?

You give/don't give tPa knowing it's wrong ("either way" or at least half the time) causing either unnecessary rebleed [if given] or unnecessary stroke evolution [if not given]?

You follow "floor policies" knowing they don't make any sense, as long as they can be who to be actual "policy" and as long as someone can produce the policy paperwork?

You give a last two drugs (PPI and octreotide) knowing they aren't beneficial (yet carry a potential side effect profile and cost) as long as an admitting doctor "wants it" and "asks for" it?

And, you tell the residents "always do what is in the best interest of the patient, and you'll never be wrong"?

 

[deleted109597]

For many years you ordered blood cultures for all admitted pneumonias knowing it was wrong (carried cost with no benefit and could have false positives negatively altering patient care) but you no longer do?

For years it was a federal mandate. Now it no longer is. Because it was successfully challenged.

You currently allow orders to be placed in triage, knowing many of them will be wrong (inflate healthcare costs, lead to unnecessary radiation, lead to more testing to follow up irrelevant incidentals)?

Some other provider is ordering them, or they're following the "standing delegated orders" put in place by the medical director. I can't make other providers do anything. That especially includes the director.

You give/don't give tPa knowing it's wrong ("either way" or at least half the time) causing either unnecessary rebleed [if given] or unnecessary stroke evolution [if not given]?

Honestly, I've never actually ordered tPA. But I have had patients where the neurologist either does or doesn't order it. Typically I spend a long time discussing tPA risks and benefits with patients. I wouldn't want it, and wouldn't give it to my family, unless it were palliative. And that's what I tell people.

You follow "floor policies" knowing they don't make any sense, as long as they can be who to be actual "policy" and as long as someone can produce the policy paperwork?

Can't change policy at night. Can make them show me that it exists, as opposed to the usual "just do what the floor charge nurse says." But it does require unpaid time on multiple committees to show the errors of their ways. Most EPs aren't willing to do this.

You give a last two drugs (PPI and octreotide) knowing they aren't beneficial (yet carry a potential side effect profile and cost) as long as an admitting doctor "wants it" and "asks for" it?

Gives me the opportunity to argue with them. Also, once it is their patient, I can't make them do anything.

And, you tell the residents "always do what is in the best interest of the patient, and you'll never be wrong"?

Except when it isn't.

You have to pick and choose your battles. I choose to challenge a lot. You apparently chose to challenge nothing, and left the specialty, but came back after missing "something." (likely money)
Policies don't change on their own, and they never change if nobody is acting as an agent for change. The reason medicine takes 20 years from evidence to practice is because everyone just "keeps on keeping on" instead of informing people when they aren't up to date, and just keeping their head down. Out in the community, if you think feeding your family depends on keeping quiet, then you can do that, or leave (the city, the group, the specialty, whatever). Or you can choose to be an advocate for good medicine.
Pick your battles.

 

[Birdstrike]

Double post

 

[Birdstrike]

You apparently chose to challenge nothing, and left the specialty

Sort of, but not exactly. I left and never looked back, but the landscape changed in the meantime and now some would say I am technically still in EM (though it sure doesn't feel like it).

, but came back after missing "something." (likely money)

Lol. No. That couldn't be farther from the truth. Haven't "missed" anything, as I am doing quite well. Nice attempt at ad hominem, though.

Policies don't change on their own, and they never change if nobody is acting as an agent for change.

I agree, and there's no stronger vote for change, than one cast with the feet. Also, I'm quite content with my contribution to the specialty, which however very small, will likely make a lasting impression, even after I'm gone (in a way I've chosen not to even mention or discuss on this forum).

Pick your battles.

Y e s . . . . which was exactly my point to the OP (and posted this, below).

Choose your battles...

 

[Birdstrike]

Regardless of the above thread derailment, I share the frustrations of "iish" in the OP. This is much bigger than what to do with a symptomatic hypertension. Despite anyone's talk of "academic purity" or 100% adherence to "evidence based" practice, I think many have lost sight of how much we as physicians are profoundly bullied by the system. Whether it's Joint Commission "mandating" something we strongly disagree with (which they don't actually do, since they're a non-governmental not-for profit agency some states use for hospital accreditation as a condition of Medicaid participation, and others don't), to feeling pressure to prescribe antibiotics or opiates in the name of patient satisfaction, or order tests and CT scans of questionable necessity in the name of "defensive medicine," or to change best practice to meet some "floor policy" we disagree with, or whether it's pressure to work faster than we feel is comfortable and safe to meet profit-driven metrics, or pressure to order an unproven medicine to keep an admitting doctor happy, or Medicare cutting our pay based on unproven or even patient-harmful metrics (coming soon with a Medicare HCAHPS), to insurance companies declining outpatient physicians work ups....We should be fully aware how powerless we as physicians and our scientific and evidence-based methods have truly become.

 

[deleted109597]

Regardless of the above thread derailment, I share the frustrations of "iish" in the OP. This is much bigger than what to do with a symptomatic hypertension. Despite anyone's talk of "academic purity" or 100% adherence to "evidence based" practice, I think many have lost sight of how much we as physicians are profoundly bullied by the system. Whether it's Joint Commission "mandating" something we strongly disagree with (which they don't actually do, since they're a non-governmental not-for profit agency some states use for hospital accreditation as a condition of Medicaid participation, and others don't), to feeling pressure to prescribe antibiotics or opiates in the name of patient satisfaction, or order tests and CT scans of questionable necessity in the name of "defensive medicine," or to change best practice to meet some "floor policy" we disagree with, or whether it's pressure to work faster than we feel is comfortable and safe to meet profit-driven metrics, or pressure to order an unproven medicine to keep an admitting doctor happy, or Medicare cutting our pay based on unproven or even patient-harmful metrics (coming soon with a Medicare HCAHPS), to insurance companies declining outpatient physicians work ups....We should be fully aware how powerless we as physicians and our scientific and evidence-based methods have truly become.

100% agree.

 

[deleted109597]

I did not want to engage in polypharmacy by giving her a longer acting antihypertensive either as she had held steady in the 180s/90s. When she got to the OSH her BP was back over 200 systolic and she had a HA (presumably from all the screaming) and c/o blurry vision, neither of which she had at our hospital when I had seen her. I didn't want to argue during conference so I just took it, but as per the practice patterns I've gathered in the ED in my short time as a resident, we d/c patients with that BP all the time, so what's wrong with transfer to another hospital?

Absolutely nothing. This is one of those things where everyone second guesses us. The problem is, the pt had hypertension. Or diabetes. Or some other disease you can't cure in the ED. Thus, even if you treat their condition, it will continue at some point after you stop taking care of them.