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.
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.