Judicious IV ant-hypertensive use ideas?

[Dred Pirate]

Hello all.

I am an IM pharmacist at my hospital and have been tasked with working with our hospitalist team to work on judicious IV ant-hypertensive use. I am curious as to if any of you have done things at your hospital to work on limiting the use to just true hypertensive emergencies based on several studies that have come out that sometimes we do more harm than good treating asymptomatic hypertension in the hospital. I am not taking about ICU use - just med-surg floor use.

I know education is the one thing that always comes up, but as you all know that doesn't always give you much bang for your buck, especially when dealing with nursing having their typical high turnover rate and thousands of individuals in the hospital. I think our hospitalist group would be an easy target to train, but then we have the surgeons who would be more difficult to change behavior.

Have any of you implememted specific policies? or orderset changes? One idea was that you have to list a specific symptoms (not just the SBP or MAP) that has to be met in order for the RN to give the med? I know that likely would increase calls to the physician "My patient has a SBP of 180 but no symptoms, but I feel we need to treat". Another idea was to limit to orders to "once prn" as to limit the doses they receive, but I am not totally sold on that one.

Thoughts?

thanks all

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[rokshana]

Hello all.

I am an IM pharmacist at my hospital and have been tasked with working with our hospitalist team to work on judicious IV ant-hypertensive use. I am curious as to if any of you have done things at your hospital to work on limiting the use to just true hypertensive emergencies based on several studies that have come out that sometimes we do more harm than good treating asymptomatic hypertension in the hospital. I am not taking about ICU use - just med-surg floor use.

I know education is the one thing that always comes up, but as you all know that doesn't always give you much bang for your buck, especially when dealing with nursing having their typical high turnover rate and thousands of individuals in the hospital. I think our hospitalist group would be an easy target to train, but then we have the surgeons who would be more difficult to change behavior.

Have any of you implememted specific policies? or orderset changes? One idea was that you have to list a specific symptoms (not just the SBP or MAP) that has to be met in order for the RN to give the med? I know that likely would increase calls to the physician "My patient has a SBP of 180 but no symptoms, but I feel we need to treat". Another idea was to limit to orders to "once prn" as to limit the doses they receive, but I am not totally sold on that one.

Thoughts?

thanks all

You plan on taking the legal liability of a pt stroking out?
Funny you decided that hospitalists are “easy targets”… because you think you can make them do what you want them to do?
How many times are you having a hospitalist prescribed an IV hypertensive that turns out not to be warranted… you do know there can be other reasons for an IV medication that is not just treating a number… and how many of those unwarranted orders are from MD/DOs vs midlevels?
I get it that your hospital is looking to save money, but you probably need to look to where the problem is originating from and work from there… not look to put more handcuffs on physicians.

 

[Dred Pirate]

You plan on taking the legal liability of a pt stroking out?
Funny you decided that hospitalists are “easy targets”… because you think you can make them do what you want them to do?
How many times are you having a hospitalist prescribed an IV hypertensive that turns out not to be warranted… you do know there can be other reasons for an IV medication that is not just treating a number… and how many of those unwarranted orders are from MD/DOs vs midlevels?
I get it that your hospital is looking to save money, but you probably need to look to where the problem is originating from and work from there… not look to put more handcuffs on physicians.

first you are taking what I am saying completely out of context- or maybe I did a bad job explaining the backstory.
1. This is an effort that was brought to me by the head of our hospitalist group - not initiated by myself or anyone in the pharmacy.
2. Studies have shown that we often do more harm than good by using IV anti-hypertensives to treat asymptomatic HTN, mainly because the RN is just treating the number vs treating the patient (just like you said there are reasons other than the number).
3. This is about judicious use, not eliminating the use - ensuring we don't get the generic prn anti-HTN orders on every pt vs treating true hypertensive emergencies (again, not treating asymptomatic HTN)
4. I never once mentioned $$ being saved, and that is not the point of this discussion - it is about ensuring the patients are treated correctly.
5. I said the hospitalists were easy targets to train because they are a smaller group who are more invested vs other specialties that are more disseminated through out the community - not because I can "make them do what I want to do"
6. but I do agree with you on the midlevels vs physicians-

 

[mszzeta]

You plan on taking the legal liability of a pt stroking out?
Funny you decided that hospitalists are “easy targets”… because you think you can make them do what you want them to do?
How many times are you having a hospitalist prescribed an IV hypertensive that turns out not to be warranted… you do know there can be other reasons for an IV medication that is not just treating a number… and how many of those unwarranted orders are from MD/DOs vs midlevels?
I get it that your hospital is looking to save money, but you probably need to look to where the problem is originating from and work from there… not look to put more handcuffs on physicians.

Medical practice should be for the patients' best interest. There an extensive body of science and clinical evidence that treating high BP (below 180/90) in the hospital dose NOT make any sense, unless in certain special clinical scenarios (such as CHF). The rationale for treating HTN to prevent stroke is based on cohort with YEARS of follow up, and a small difference can be detected statistically. The benefit of preventing stroke for a few days of treatment would be negligible, and the harm would outweigh the benefit (people can get infected or PE in the hospital that low BP can be dangerous)

Similarly, for asymptomatic patients whose BP > 180/90 without other special situation, it is totally justifiable to give PO BP meds. The standard care for for asymptomatic patients whose BP > 180/90 without other special scenarios in ED is to discharge and PCP follow up. ("Hypertensive urgency is NOT an emergency" It is outpatient rather than ED management)

Overall, I completely agree with OP about stopping the non-sense practice

 

[whoknows2012]

De

Medical practice should be for the patients' best interest. There an extensive body of science and clinical evidence that treating high BP (below 180/90) in the hospital dose NOT make any sense, unless in certain special clinical scenarios (such as CHF). The rationale for treating HTN to prevent stroke is based on cohort with YEARS of follow up, and a small difference can be detected statistically. The benefit of preventing stroke for a few days of treatment would be negligible, and the harm would outweigh the benefit (people can get infected or PE in the hospital that low BP can be dangerous)

Similarly, for asymptomatic patients whose BP > 180/90 without other special situation, it is totally justifiable to give PO BP meds. The standard care for for asymptomatic patients whose BP > 180/90 without other special scenarios in ED is to discharge and PCP follow up. ("Hypertensive urgency is NOT an emergency" It is outpatient rather than ED management)

Overall, I completely agree with OP about stopping the non-sense practice

Wholeheartedly agree

 

[InternistDO]

I think unfortunately the only answer is RN education. I would happily ignore all blood pressures overnight in asymptomatic patients (and let's be real, in most "symptomatic" ones too) but I don't have it in me to argue with nurses terrified about their patient's head exploding 3-5 times a night. So even if the hospitalists are on board they may be up against a lot of ingrained resistance, especially if surgery is still doing it.

I'm off the mind that IV antihypertensives should never be pushed on the floor. Either they have a real HTN emergency and need ICU/step down, or they don't and they need nothing (or if you want to amuse yourself doing nothing, some PO hydralazine). That could be a policy that's effective.

 

[NotAProgDirector]

When trying to address a problem like this, it's critical to explore the "workflows" and get to the root cause. Patients are getting doses of IV antihypertensives on the floor that, in retrospect, appear to have little benefit. The question is why? Is it because the physicians actually want that to happen because they think it's good for patient care? In that case, either physician education or some sort of CDS (clinical decision support) like an order set or alert might help. But it's more likely that this is driven by nursing culture - they get a high BP and then they feel like they need to call someone. That can sometimes be because of the admission orders telling them to do so (i.e. "call MD/DO for SBP > 160") - one of those orders that are often on an order set that we never think about. Or it's just "what happens". And if that's the case, then people put these orders in to prevent calls -- especially at night.

If this is driven by nursing, it's unlikely that changing anything in the order will make any difference. If the nurse is concerned, they will call. Your best solution is to connect with nursing leadership and develop a policy and job aid. This gets publicized and socialized, and you try to change behavior. But it's still hard, and you'll still get nurses calling docs at 2AM for an SBP of 168 "FYI, just in case".

 

[gutonc]

When trying to address a problem like this, it's critical to explore the "workflows" and get to the root cause. Patients are getting doses of IV antihypertensives on the floor that, in retrospect, appear to have little benefit. The question is why? Is it because the physicians actually want that to happen because they think it's good for patient care? In that case, either physician education or some sort of CDS (clinical decision support) like an order set or alert might help. But it's more likely that this is driven by nursing culture - they get a high BP and then they feel like they need to call someone. That can sometimes be because of the admission orders telling them to do so (i.e. "call MD/DO for SBP > 160") - one of those orders that are often on an order set that we never think about. Or it's just "what happens". And if that's the case, then people put these orders in to prevent calls -- especially at night.

If this is driven by nursing, it's unlikely that changing anything in the order will make any difference. If the nurse is concerned, they will call. Your best solution is to connect with nursing leadership and develop a policy and job aid. This gets publicized and socialized, and you try to change behavior. But it's still hard, and you'll still get nurses calling docs at 2AM for an SBP of 168 "FYI, just in case".

This is a culture issue, not a medical, nursing or patient care issue. And culture eats strategy for breakfast.

I'm not saying it can't be done, but it's going to have to be a very broad ranging project involving physician, nursing and pharmacy leadership from the very beginning. And once a policy/orderset/job aid is in place, it's going to take time and effort to make it actually work, on all sides.

 

[Splenda88]

Talking to my colleagues, most of us (probably all of us to be honest) don't care about asymptomatic high blood pressure in the hospital.

If you don't place an IV PRN order, you will be getting constant calls from nurse about asymptomatic high BP.

I had calls about asymptomatic BP of 150s/100s telling me that 'you need to do something for the high diastolic'.


In all honesty, I can say as a former RN, it's not the nurses' fault. It's just the way they are taught in nursing school.

 

[Splenda88]

I think unfortunately the only answer is RN education. I would happily ignore all blood pressures overnight in asymptomatic patients (and let's be real, in most "symptomatic" ones too) but I don't have it in me to argue with nurses terrified about their patient's head exploding 3-5 times a night. So even if the hospitalists are on board they may be up against a lot of ingrained resistance, especially if surgery is still doing it.

I'm off the mind that IV antihypertensives should never be pushed on the floor. Either they have a real HTN emergency and need ICU/step down, or they don't and they need nothing (or if you want to amuse yourself doing nothing, some PO hydralazine). That could be a policy that's effective.

Bingo. Ignore my post above