Standard operating procedure for the management of hypertensive urgencies in a community health centre in rural Tamil Nadu: a quality improvement project
Keywords:Hypertensive urgency, Hypertensive crises, SOP, PDSA, Rural
Background: Hypertension is one of the heaviest health care burdens in rural India where less than 1/10th of patients has blood pressures under control. This sheds limelight on community healthcare centers to proactively prevent, manage and treat hypertension and its complications. St. Ann’s Hospital is one such CHC located in the Elathigiri subdisrtict of Tamil Nadu. We formulated a standard operating procedure at the CHC for the effective prevention and treatment of hypertensive urgency- one of the easily treatable but highly impactful complications of hypertension. We then strengthened its usage using plan-do-study-act cycles
Methods: An SOP was formulated using international and national guidelines, contoured to the low resources present at the center. Healthcare workers were trained to follow the SOP. Sequential PDSA cycles were then used to evaluate and control the step-ladder of barriers in effective management. The results were analyzed using indicators and compared to baseline values established at the start of the study.
Results: A rise of 41.4% was seen in correct SOP execution at the end of PDSA-2. At the end of the study, there was a 22% increase in the percent of patients correctly diagnosed, 19% increase in patients stabilized in the first hour and 14% increase in patients returning for follow up visits (p<0.05).
Conclusions: Our SOP could significantly reduce the burden of HU at the CHC. We encourage its usage in similar low resource centers and promote PDSA cycles as a method to ensure its efficient utilization.
Anchala R, Kannuri NK, Pant H, Khan H, Franco OH, Di Angelantonio E, et al. Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens. 2014;32(6):1170-7.
Bhansali A, Dhandania VK, Deepa M, Anjana RM, Joshi SR, Joshi PP, et al. Prevalence of and risk factors for hypertension in urban and rural India: the ICMR–INDIAB study. J Hum Hypertens. 2015;29(3):20-9.
Governatori N, Pollack CV. Chapter 65 - Hypertensive Crisis. In: Levine GN, editor. Cardiology Secrets 5th ed. Netherland: Elsevier; 2018:557-63.
Aronow WS. Treatment of hypertensive emergencies. Ann Transl Med. 2017;5(1):S5.
2017 Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American college of cardiology/american heart association task force on clinical practice guidelines. Available at: https://read.qxmd.com/read/29133356/2017-acc-aha-aapa-abc-acpm-ags-apha-ash-aspc-nma-pcna-guideline-for-the-prevention-detection-evaluation-and-management-of-high-blood-pressure-in-adults-a-report-of-the-american-college-of-cardiology-american-heart-association-task-force-on-clinical-practice. Accessed on 20 November 2021.
Benenson I, Waldron FA, Jadotte YT, Holly C. Risk factors for hypertensive crisis in adult patients: a systematic review protocol. JBI Evid Synt. 2019;17(11):2343-9.
Vaiyapuri S, Vaiyapuri R, Ashokan R, Ramasamy K, Nattamaisundar K, Jeyaraj A, et al. Snakebite and Its Socio-Economic Impact on the Rural Population of Tamil Nadu, India. PLOS One. 2013;8(11):e80090.
Peixoto AJ. Acute severe hypertension. New Eng J Med. 2019;381(19):1843-52.
Bhatia M, Kumar M, Dixit P, Dwivedi LK. Diagnosis and Treatment of hypertension among people aged 45 years and over in India: a sub-national analysis of the variation in performance of Indian States. Front Public Health. 2021;9:67-9.
Morgan AJ, Rapee RM, Bayer JK. Increasing response rates to follow-up questionnaires in health intervention research: Randomized controlled trial of a gift card prize incentive. Clin Trials. 2017;14(4): 381-6.
Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Qual Saf. 2014;23(4):290-8.
McCambridge J, Witton J, Elbourne DR. Systematic review of the Hawthorne effect: New concepts are needed to study research participation effects. J Clin Epidemiol. 201;67(3):267-7.