Introduction

The question of introducing a quality improvement plan to treat hypertension in urgent care is crucial, given the current state of hypertension control in the United States. Mills et al. (2020) argue that hypertension is mostly preventable and controllable. However, progress in improving hypertension control has stalled over the last decade, and the ongoing COVID-19 pandemic has disrupted preventive care and presented barriers to hypertension control. Kirkland et al. (2018) emphasize that without improvements in healthy lifestyle behaviors and healthcare delivery, the decade-long improvements in cardiovascular health will erode. Furthermore, Bhutani et al. (2021) and Czeisler et al. (2020) note that the pandemic has led to worsening mental health and unhealthy coping mechanisms such as unhealthy eating and decreased physical activity, further exacerbating hypertension control.

Addressing the disparities in hypertension awareness, treatment, and control among racial and ethnic populations in the United States is critical. The Centers for Disease Control and Prevention [CDC] (2021) argue that this issue must be addressed, given ample evidence for the prevention and control of hypertension. Additionally, Himmelfarb et al. (2016) highlight the role of nurses in preventing and managing hypertension. Hence, introducing a quality improvement plan that accounts for racial and ethnic disparities and promotes the involvement of nurses could significantly improve hypertension control in urgent care settings.

The 2020 Surgeon Generals Call to Action to Control Hypertension identified three broad goals in response to worsening hypertension control. The goals are to (1) make hypertension a national priority, (2) ensure that places where people live, work, and play support hypertension control, and (3) optimize patient care for hypertension control (U.S. Department of Health and Human Services, 2020a; Judith et al., 2022). Thus, introducing a quality improvement plan should align with these goals and ensure that it accounts for the broader context of hypertension control.

Thesis

Regarding hypertensive urgencies, there is a lack of Canadian data on whether referrals to the emergency department (E.D.) regarding hypertension are appropriate. Recent guidelines advise against referring patients with hypertensive urgencies to the E.D. for treatment. Referrals to the Montfort Hospital E.D. due to hypertension were analyzed and assessed if they met the criteria for hypertensive emergencies (Richard et al., 2021). Therefore, any quality improvement plan for treating hypertension in urgent care must account for the appropriate management of hypertensive urgencies to avoid unnecessary referrals to the E.D.

Despite recommendations to optimize oral antihypertensive regimens with appropriate follow-up care for hypertensive urgencies, many patients are referred to overcrowded emergency rooms for unrequired acute care. There is currently a lack of specific data from Canadian institutions regarding the incidence of true hypertensive emergencies (Richard et al., 2021). As such, any quality improvement plan aimed at treating hypertension in urgent care settings should ensure that patients with hypertensive urgencies receive the appropriate care to avoid unnecessary referrals to the E.D. and improve hypertension control.

Background

Hypertension is a major global health concern, and effective treatment is essential to prevent serious complications. The American College of Cardiology (ACC), together with the American Heart Association (AHA), published new guidelines in 2017 recommending intensive blood pressure (B.P.) control to reduce the risk of cardiovascular events and mortality. However, there is some uncertainty regarding the optimal B.P. targets. Recent trials, such as SPRINT and ACCORD, yielded mixed results. More intensive B.P. control significantly reduced cardiovascular events and mortality in some studies but not in others. These findings highlight the need for effective quality improvement plans to improve hypertension treatment in urgent care settings (Xu, Zhang, & Kwak, 2019; Sadeghi et al., 2020).

To effectively manage hypertension, clinicians must know the ACC/AHA guidelines and classify patients according to their B.P. level. Lifestyle modifications and BP-lowering medications are recommended for patients with stage 1 or 2 hypertension, and close follow-up is necessary to monitor B.P. However, achieving B.P. control can be challenging due to multiple barriers, including patient adherence to medication, accurate B.P. measurement, and a lack of appropriate guideline-based therapy. To address these barriers, interventions such as non-pharmacological therapy, medication reconciliation, and education for physicians, nursing staff, and patients can be effective (Burnier & Egan, 2019; Mondoux, 2020).

Discussion

In addition to these interventions, specific strategies can address patient-related barriers to hypertension treatment, such as medication non-adherence and missed appointments. Prescription of generic medications and combination therapy can improve medication adherence, and providing a 90-day supply can overcome transportation barriers to the pharmacy. Home B.P. monitoring and increased clinic visits can improve patient engagement and communication, leading to better medication adherence and education counseling. Older patients and those with fewer medications may have higher adherence, and phone coaching can effectively mprove medication adherence, home B.P. monitoring, and lifestyle modifications (Uchmanowicz et al., 2019; Sadeghi et al., 2020).

When managing hypertensive urgencies, referrals to the emergency department may not always be necessary. Canadian data is lacking in this area, and assessing whether referrals meet the criteria for hypertensive emergencies is important. This highlights the need to effectively manage hypertensive urgencies in urgent care settings to prevent unnecessary referrals and ensure appropriate treatment (Richard et al., 2021). Implementing a quality improvement plan that addresses the multiple barriers to hypertension treatment can be effective in urgent care settings. This plan should include strategies to improve patient adherence to medication and appointments, medication reconciliation, physician education, and appropriate management of hypertensive urgencies. By following ACC/AHA guidelines and utilizing these interventions, clinicians can provide better care for patients with hypertension and prevent serious complications.

Plan for Q.I. Project

To introduce a quality improvement plan for hypertension treatment in urgent care, we will conduct a retrospective cohort study from April 1 to April 31, 2023, using electronic health record data from 10 Cleveland Clinic Hospitals. This study is approved by the institutional review board of Cleveland Clinic, and we will seek a consent waiver because the study poses minimal risk to participants. The study will follow the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline (Rastogi et al., 2021).

Cohort

In our cohort, we will include patients older than 18 years admitted to a medicine service, excluding those with a cardiovascular diagnosis or admission within the past 30 days for acute coronary syndrome or cerebrovascular events, pregnant patients, and those with a length of stay less than two or greater than 14 days. For patients with multiple admissions, we will randomly select a single admission. Patients without outpatient medication data will also be excluded (Rastogi et al., 2021).

Measures

We will collect all systolic blood pressures (SBPs), diastolic blood pressures (DBPs), and heart rates, excluding measurements from the intensive care unit. Hypertension will be defined by an SBP measurement of at least 140 mm Hg.

Adjusters

We will collect patient characteristics associated with treatment, including demographic details (age, sex, and race/ethnicity) obtained from medical records, comorbidities (cardiovascular disease, diabetes, and chronic kidney disease), and B.P. characteristics, including the maximal SBP and DBP, time from admission in hours, hospital shift during which the B.P. was measured, change from prior SBP, and proportion of the previous two measures that were elevated. Race/ethnicity will be included in the analysis, as hypertension disparities and antihypertensive intensification disparities are well established. Race/ethnicity options will be defined by the health system (Rastogi et al., 2021).

Medications

We will collect all medications administered before, during, and after admission to classify medications. We will use the 2017 Guideline for High Blood Pressure in Adults to classify medications, excluding spironolactone and loop diuretics. The antihypertensive drug classes we will include are angiotensin-converting enzyme inhibitors, calcium channel blockers, angiotensin receptor blockers (subtype 2), ?-blockers, direct-acting vasodilators, central ?2-receptor agonists, potassium-sparing diuretics, thiazide diuretics, and peripheral ?1-receptor blockers. We will categorize the route of administration as intravenous (IV), oral, or other (e.g., transdermal or intramuscular) (Rastogi et al., 2021).

Expected Outcomes

In introducing a quality improvement plan to treat hypertension in Urgent Care, the initial step will be the acute treatment of elevated blood pressure. This will...

…hours. For individual disease processes, additional guidelines exist to tailor B.P. management, and the optimal B.P. goal for immediate intervention may be greater than 25% of MAP. The most common medications indicated for treatment are nicardipine, labetalol, clevidipine, and esmolol. While nitroprusside was a mainstay of treatment for decades, antihypertensive medications such as nicardipine and clevidipine demonstrate similar efficacy, are easy to titrate, and have no concern for possible cyanide toxicity. The existing literature does not provide sufficient evidence to show that any specific IV antihypertensive agent is superior to another, though the dihydropyridine agents (nicardipine and clevidipine) and labetalol, are preferred agents in the setting of neurological hypertensive emergencies (Miller et al., 2020).

Recommendations

To evaluate the quality improvement plan to treat hypertension in urgent care, it is essential to prioritize continuity of care and collaboration between healthcare providers. Patients who receive follow-up care after discharge from urgent care centers are more likely to manage their health conditions effectively. Therefore, policies should be developed to improve access to care and inspire patients to be proactive in their healthcare (Hayes 2017). A patient-centered team that focuses on the patients individual needs can increase the patients longevity and quality of life while cutting down the cost and disabilities linked with untreated high blood pressure. Evaluating the success of the quality improvement plan should include metrics such as the number of patients who received follow-up care, patient satisfaction, and the cost savings associated with improved health outcomes.

The use of health information technology is crucial for managing chronic conditions like hypertension and improving collaboration between healthcare providers. An interoperable healthcare system that allows the exchange of healthcare information among the healthcare team can ensure continuity of care between the patients primary care provider (PCP) and the urgent care provider. Unfortunately, few health information systems can comunicate outside their providers, making it difficult for individual urgent care facilities and PCPs to share information promptly (Hayes 2017). To evaluate the quality improvement plan, it is necessary to assess the use of health information technology, including electronic medical records (EMRs) and telemedicine, to ensure seamless communication and coordination of care.

Additional research might be needed to establish best practices for treating hypertension in urgent care settings. A study introduced an intervention that involved making appointments with PCPs for patients with elevated blood pressure in an urgent care visit to deal with the issue of follow-up care. While the results were significant, this study only addressed one variable, and other barriers to follow-up care must be considered (Hayes 2017). To evaluate the quality improvement plan, it is necessary to consider additional variables and replicate the study in other settings to determine the best practices for improving follow-up care.

Conclusion

Early detection and treatment of elevated blood pressure can improve health outcomes and decrease costs associated with heart disease, the key cause of death in the United States. The study results might be consistent with other studies that support making referrals for follow-up care before patients leave urgent care facilities. However, to ensure the success of the quality improvement plan, policies should be developed to ensure continuity of care between urgent PCPs and care facilities. In addition, healthcare systems that allow EMRs to be shared between urgent PCPs and care facilities should be developed. Further research should be conducted to develop best practice policies for treating hypertension in urgent care settings.

To evaluate the quality improvement plan to treat hypertension in urgent care, it is essential to focus on patient-centered care, collaboration, and health information technology. Metrics such as the number of patients who received follow-up care, patient satisfaction, and cost savings should be used to evaluate the plans success. Implementing policies that ensure continuity of care and the development of healthcare systems that allow the exchange of EMRs between urgent care facilities and PCPs is crucial for the success of the quality improvement plan. Further research should be conducted to identify best…