A quality improvement project evaluating the perioperative implementation of a hypertension management protocol by anaesthesiologists at seven government hospitals in the Western Cape. “a multi-center, cross-sectional quality improvement project: the peri-operative implementation of a hypertension protocol by anesthesiologists”
BACKGROUND: Hypertension is a common risk factor for cardiovascular morbidity and mortality, with a high prevalence in patients presenting for elective surgery. In limited resource environments, patients have poor access to primary care physicians, limiting the efficacy of life-style modification for the initial management of hypertension in the community. In these circumstances, the perioperative period presents a unique opportunity for diagnosis and initiation and/or modification of pharmacotherapy of hypertension. Anesthesiologists are ideally placed to lead this aspect of perioperative medicine. METHODS: In collaboration with expert physicians, we designed and implemented an algorithm for the diagnosis of hypertension and subsequent initiation or modification of anti-hypertensive therapy, or referral to a physician. The study was a multi-center, cross-sectional quality improvement project in seven hospitals in the Western Cape, South Africa. On the day before scheduled elective surgery, adult inpatients had two sets of blood pressure (BP) readings taken, one by nurses and the other by anesthesiologists, using a noninvasive automated blood pressure device. These were averaged on an electronic database, to diagnose hypertension. Patients with normal BP or well-controlled hypertension required no further management. Those with borderline BP received educational pamphlets. Patients with stage 1 or 2 hypertension were managed with medication according to the algorithm, starting 1 day postoperatively, and provided with educational pamphlets. Patients with stage 3 disease were referred to a physician. The primary outcome was adherence by the anesthesiologist to the algorithm, defined as initiation of the prescribed medication. An 80% adherence rate was considered successful implementation. The secondary outcome was the issue of the antihypertensive medication at discharge. RESULTS: Two hundred and ninety-eight patients were screened for hypertension. One hundred and six patients were eligible for the quality improvement project. Thirty-seven (34.9%) had borderline blood pressure readings, 43 (40.6%) had stage 1-, 22 (20.8%) stage 2-, and 4 (3.8%) stage 3 hypertension respectively. The adherence rate by the anesthesiologist was 84.0% (95% confidence interval (CI) 77.0% to 91.0%) for initiation of anti-hypertensive therapy. It was noted that 55.5% (95% CI 46.2% to 65.1%) received their medication upon discharge. CONCLUSIONS: Anesthesiologists successfully implemented a quality improvement project for diagnosis and management of hypertension in the perioperative period. This has the potential to reduce the public health burden of hypertension in limited resource environments. Successful ongoing prescription and follow-up requires cooperation within a multi-disciplinary team involving anesthesiologists, surgeons, nurses, pharmacists and physicians.
Anaesthesiology and Perioperative Medicine
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Department of Anaesthesia and Perioperative Medicine