Implementing a quality improvement initiative for reducing intravenous antihypertensive utilization in the hospital setting: Improving patient outcomes without prolonging hospital stay

Moez Alnazeer; Jessica Jones; David Ficklen

doi:10.12688/f1000research.135165.1

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Research Article

Implementing a quality improvement initiative for reducing intravenous antihypertensive utilization in the hospital setting: Improving patient outcomes without prolonging hospital stay

[version 1; peer review: 1 approved with reservations, 1 not approved]

Moez Alnazeer ^1,2, Jessica Jones¹, David Ficklen^1,2

PUBLISHED 18 Jul 2023

Author details Author details

¹ CHI St Joseph Regional Health Center, Bryan, Texas, 77802, USA
² Texas A&M University, College Station, Texas, 77840, USA

Moez Alnazeer
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Jessica Jones
Roles: Data Curation, Formal Analysis, Resources, Writing – Review & Editing

David Ficklen
Roles: Conceptualization, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

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This article is included in the Health Services gateway.

Abstract

Background: This project aimed to implement a quality improvement initiative to reduce the utilization of non-indicated intravenous (IV) antihypertensive medications in the hospital setting and evaluate its impact on hospital length of stay.
Methods: A quality improvement initiative was conducted at a 500-bed regional hospital to improve management of inpatients with asymptomatic severe hypertension. An algorithm was developed to guide management to minimize the inappropriate use of IV antihypertensives. Educational sessions were conducted with medical providers and nursing staff to promote adherence to the algorithm. Pharmacy records were reviewed to assess the utilization of IV antihypertensive medications. Aggregated length of hospital stay before and after the intervention were compared. Statistical analysis was performed using paired t-tests.
Results: The utilization of IV antihypertensive medications was reduced by 47.6% after the intervention, as measured by days of therapy per 1000 patient days (p <0.001). However, the average length of hospital stay did not show a significant difference before and after the intervention (p = 0.094).
Conclusions: The implementation of a quality improvement initiative, including an algorithm and education for healthcare staff, successfully reduced the utilization of non-indicated IV antihypertensive medications in the hospital setting. This approach has the potential to improve patient safety and reduce healthcare costs. Further research is needed to explore the long-term effectiveness of this intervention and its impact on patient outcomes.

Keywords

quality improvement initiative, IV antihypertensive medications, hospital setting, length of stay, patient safety, healthcare costs

Corresponding author: Moez Alnazeer

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Alnazeer M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Alnazeer M, Jones J and Ficklen D. Implementing a quality improvement initiative for reducing intravenous antihypertensive utilization in the hospital setting: Improving patient outcomes without prolonging hospital stay [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2023, 12:843 (https://doi.org/10.12688/f1000research.135165.1) First published: 18 Jul 2023, 12:843 (https://doi.org/10.12688/f1000research.135165.1) Latest published: 18 Jul 2023, 12:843 (https://doi.org/10.12688/f1000research.135165.1)

Introduction

Hypertension is a common condition seen in hospitalized patients. Aggressive management with intravenous (IV) antihypertensive medications is often inappropriately utilized for asymptomatic patients with severe hypertension.¹ However, there is a lack of evidence to support the routine use of IV antihypertensive medications in this population.² Studies have shown an increased risk of complications, such as acute kidney injury, cerebral vascular accident, myocardial infarction, dizziness, and falls, associated with this practice.³^–⁵ In addition to the potential harm to patients, this approach also leads to increased healthcare costs.

To address this issue, an algorithm was developed (Figure 1) to guide nursing and medical staff in the management of asymptomatic patients with severe hypertension with the goal of reducing the blood pressure moderately and slowly using oral medications when appropriate. The primary objective of this project was to evaluate the effect of this intervention on the utilization rates of IV antihypertensive medications after providing education on the flowchart pathway to nursing and medical staff. The secondary objective was to assess the impact of the intervention on length of stay.

Figure 1. The algorithm used to assist in managing severe hypertension in the hospital setting.

Methods

Ethical considerations

The project involved reviewing aggregate pharmacy data that were de-identified. No patient records were accessed and the project involved minimal risks. Quality improvement initiatives do not require IRB approval per our institutional guidelines and the US Department of Health Services Regulations. An informed consent form was used to obtain consent from the participants of this project.

Project setting

This project was conducted at a 500-bed community hospital, College Station, Texas. Patients in the Emergency Department, Intensive Care Unit and Stroke Unit were excluded based on the appropriate need for IV antihypertensive medications in these areas.

Data collection

Aggregated hospital inpatient pharmacy data regarding the utilization of intravenous (IV) antihypertensive medications was extracted for the months of July 2022 through March 2023.⁶ This data identified the types of IV antihypertensive medications utilized during the project period. Hydralazine and labetalol represented over 90% of the IV antihypertensive doses given during the project period. Therefore, this project focused on these two drugs. The data were collected and recorded in a secure electronic database for analysis. Overall length of stay data were obtained from case management department data.

Outcome measure

The primary outcome measure for this project was the difference in average monthly utilization of IV antihypertensive medications between the four-month period before and the four-month period after the intervention. The utilization was measured using the standardized “days of therapy per 1000 patient days (DOT/1000)” to account for the potential differences in patient volume and length of stay during the project period. The secondary outcome was the effect of this intervention on the average length of stay of the patient population studied.

Plan of action

An algorithm that outlined the appropriate management of severe asymptomatic hypertension in the hospital setting was created based on current evidence-based guidelines and local hospital protocols (Figure 1). This was reviewed and approved by the hospital’s Pharmacy and Therapeutics Committee.

Educational sessions

Several educational sessions were conducted with the medical staff, nursing staff, and pharmacists to discuss the management of severe asymptomatic hypertension and utilization of the suggested algorithm. These educational sessions included presentations, case discussions, and interactive discussions to promote understanding and adherence to the recommended pathway. These sessions were facilitated by a multidisciplinary team which included clinical pharmacists, clinical nurse educators, and physician champions.

Monitoring

After the completion of the educational sessions, the utilization of IV antihypertensive medications was monitored over the subsequent four-month period to assess the impact of the intervention. The utilization data were collected from the pharmacy records and recorded in the electronic database for analysis.

Data analysis

Descriptive statistics, including mean, median, standard deviation, and frequency distributions, were used to summarize the utilization of IV antihypertensive medications during the project period. The changes in utilization and length of stay before and after the intervention were compared using paired t-tests. A p-value of less than 0.05 was considered statistically significant. The Microsoft Excel 365 data analysis tool was used to conduct statistical analyses.

Results

Aggregate pharmacy data on the usage of IV antihypertensive medications were reviewed for the duration of July 2022 to March 2023 (Table 1). The primary outcome was the impact on utilization of IV antihypertensives using DOT/1000. This measure showed a significant decrease in the four-month period after the intervention 25.24 (SD = 3.05) compared to the four-month interval before the intervention 48.21 (SD = 3.06). After the intervention, the utilization rate decrease was maintained for four consecutive months measured. For the secondary outcome, the average length of stay in days for patients hospitalized did not demonstrate any statistically significant change. The average length of stay before the intervention was 4.15 (SD = 0.12), whereas after the intervention, the average length of stay was 4.375 (SD = 0.12). The average length of stay before the intervention in July, August, September, and October was 4.1, 4.3, 4.2, and 4, respectively. After the intervention, the average length of stay increased in December (4.3) and January (4.6) and decreased in February (4.4) and March (4.2) (Figure 2).

Table 1. Outline utilization data of IV hydralazine and labetalol over the duration from July 2022 to March 2023.

Month	DOT	Days present	DOT/1000
July	300	5740	52.26
August	259	5625	46.04
September	263	5732	45.88
October	247	5751	47.64
November	181	5118	35.37
December	143	5960	23.99
January	125	6053	20.65
February	139	5386	25.81
March	117	5797	20.18

Definitions: Days of therapy (DOT): Presents administrations of a specific medication on the calendar day. Days present: Number of patients present in the hospital for any portion of a calendar day. DOT/1000 patient days: DOT*1000/Days present.

Figure 2. Days of therapy/1000 patient days (DOT/1000) for IV Hydralazine and Labetalol and average length of stay in days pre-July–October 2022) and post-December 2022–March 2023 implementation of the quality improvement initiative in November 2022.

Statistical analysis

The data were analyzed using a paired t-test to compare the mean utilization rate before and after the intervention. The results showed a significant difference between the means (t(6) = 8.65, p < 0.001). The effect size was large (Cohen’s d = 3.54). For the average length of stay in days for patients hospitalized, the data were analyzed using a paired t-test to compare the mean length of stay before and after the intervention. The results showed no significant difference between the means (t(6) = -1.99, p = 0.094). The effect size was small (Cohen’s d = 0.61).

Discussion

In this project, we implemented a quality improvement initiative to reduce the utilization of non-indicated intravenous (IV) antihypertensive medications in the hospital setting. Our results showed that the implementation of an algorithm and educational sessions successfully decreased the utilization of IV antihypertensives, as measured by days of therapy per 1000 patient days. The reduction in IV antihypertensive utilization is important for patient safety and cost saving. By shifting the management approach towards oral medications, we can minimize the potential harm and increased healthcare costs associated with unnecessary IV antihypertensive use. While the intervention significantly reduced IV antihypertensive utilization, there was no significant difference in the average length of hospital stay before and after the intervention. This indicates that slowly lowering blood pressure with oral medications does not necessarily increase hospital length of stay.

There are several limitations to this project. First, the project was conducted in a single community hospital, which may limit the generalizability of the findings to other settings. Second, the project relied on pharmacy records for data collection, which may be subject to inaccuracies or missing data. Third, the project was conducted over a relatively short time frame of four months. This may not capture long-term changes in utilization patterns. Finally, the project did not assess the impact of the intervention on patient outcomes, such as blood pressure control or adverse events, which may provide further insights into the effectiveness of the intervention.

Conclusions

A quality improvement initiative introducing an algorithm with education for nursing and medical staff, significantly reduced the utilization of IV antihypertensives using DOT/1000 but did not significantly affect the average length of stay in days for patients hospitalized. This project has shown the potential to improve patient safety by reducing the risk of complications associated with unnecessary IV antihypertensive medication use and also has the potential to reduce healthcare costs. Further research is warranted to explore the potential clinical implications of these findings and to evaluate the long-term effectiveness of the intervention in optimizing antihypertensive medication usage in this patient population.

Consent

Written informed consent for publication of the participants’ details was obtained from the participants.

Data availability

Underlying data

Figshare: Underlying data for ‘Implementing a quality improvement initiative for reducing intravenous antihypertensive utilization in the hospital setting improving patient safety without prolonging hospital stay’. https://doi.org/10.6084/m9.figshare.23523708.v1.⁶

This project contains the following underlying data:

• Implementing a Quality Improvement Initiative for Reducing Intravenous Antihypertensive Utilization in the Hospital Setting Improving Patient Safety Without Prolonging Hospital Stay.pdf.

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

References

1. Cherney D, Straus S: Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature. Gen. Intern. Med. 2002; 17(12): 937–945. PubMed Abstract | Publisher Full Text | Free Full Text
2. Kitiyakara C, Guzman N: Malignant hypertension and hypertensive emergencies. J. Am. Soc. Nephrol. 1998; 9: 133–142. Publisher Full Text
3. O’Mailia JJ, Sander GE, Giles TD: Nifedipine-associated myocardial ischemia or infarction in the treatment of hypertensive urgencies. Ann. Intern. Med. 1987; 107(2): 185. Publisher Full Text
4. Grossman E, Messerli FH, Grodzicki T, et al.: Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies. JAMA. 1996; 276(16): 1328–1331. PubMed Abstract | Publisher Full Text
5. Zeller KR, Von Kuhnert L, Matthews C: Rapid reduction of severe asymptomatic hypertension: a prospective, controlled trial. Arch. Intern. Med. 1989; 149(10): 2186–2189. PubMed Abstract | Publisher Full Text
6. Alnazeer M: Implementing a Quality Improvement Initiative for Reducing Intravenous Antihypertensive Utilization in The Hospital Setting Improving Patient Safety Without Prolonging Hospital Stay. [Dataset]. figshare. 2023. Publisher Full Text

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Version 1

VERSION 1 PUBLISHED 18 Jul 2023

Author details Author details

¹ CHI St Joseph Regional Health Center, Bryan, Texas, 77802, USA
² Texas A&M University, College Station, Texas, 77840, USA

Moez Alnazeer
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Jessica Jones
Roles: Data Curation, Formal Analysis, Resources, Writing – Review & Editing

David Ficklen
Roles: Conceptualization, Project Administration, Resources, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (1)

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Published: 18 Jul 2023, 12:843

https://doi.org/10.12688/f1000research.135165.1

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© 2023 Alnazeer M et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Alnazeer M, Jones J and Ficklen D. Implementing a quality improvement initiative for reducing intravenous antihypertensive utilization in the hospital setting: Improving patient outcomes without prolonging hospital stay [version 1; peer review: 1 approved with reservations, 1 not approved]. F1000Research 2023, 12:843 (https://doi.org/10.12688/f1000research.135165.1)

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Reviewer Report 15 Dec 2023

Ingrid Prkacin, School of Medicine, University of Zagreb, Zagreb, Croatia

Approved with Reservations

https://doi.org/10.5256/f1000research.148268.r223799

This article describes the results of a quality improvement project focusing on the reduction of intravenous antihypertensive medication use following the creation of an algorithm for the management of severe (grade III) hypertension in the emergency department and staff education.
... Continue reading

This article describes the results of a quality improvement project focusing on the reduction of intravenous antihypertensive medication use following the creation of an algorithm for the management of severe (grade III) hypertension in the emergency department and staff education.
While the topic is interesting and important, there are several questions that require answering before the article is ready for publication.
1. In the "Ethical considerations" part of the "Methods" section, it is stated that the project involved the review of de-identified pharmacy data and that no patient records were accessed. It also states that an informed consent form was used to obtain consent from the participants. Who were the participants that were required to give consent if no patient records were accessed, and the study was based on aggregated, de-identified pharmacy data?
2. In the "Plan of action" part of the "Methods" section, the authors mention that the algorithm was created based on current evidence-based guidelines and local hospital protocols but cites no such guidelines. Which guidelines were used and from what societies? Please also provide citations for these guidelines.
3. The "Educational sessions" part of the "Methods" section should be expanded and explained in more detail, outlining the curriculum used, number of sessions, topics of each session etc. (this can be provided as an Appendix or Supplemental Material) in order to make the intervention replicable in other interested institutions.
4. In "Table 1" of the "Results" section, it is stated that the DOT/1000 for March 2023 was 20.18, while in the "Underlying material" data, page 6, it is stated that the DOT/1000 for March 2023 was 30.53. Please explain this discrepancy.
5. More citations should be added, especially to the "Discussion" section, which contains none.
6. Which oral antihypertensive medications were used in place of the intravenous ones? There should be pharmaceutical data on the usage of those. Is there a trend of an increase in the use of oral antihypertensive medications in the observed period following the implementation of the algorithm?
7. The references should be of a more recent date. Also, similar interventions implemented by other authors should be discussed and presented in the "Discussion" section (for example, the study by Grassi et al. cited below).

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

References

1. Grassi D, O'Flaherty M, Pellizzari M, Bendersky M, et al.: Hypertensive urgencies in the emergency department: evaluating blood pressure response to rest and to antihypertensive drugs with different profiles.J Clin Hypertens (Greenwich). 2008; 10 (9): 662-7 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Arterial Hypertension, Chronic Kidney Disease, Emergency Medicine, Nephrology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report 18 Oct 2023

Zachary G. Jacobs, Oregon Health & Science University, Portland, Oregon, USA

Not Approved

https://doi.org/10.5256/f1000research.148268.r213669

In this research article, the authors describe a quality improvement (QI) initiative aimed at reducing the unnecessary use of intravenous (IV) antihypertensive medications at a 500-bed community hospital in Texas. The QI intervention was comprised of an educational campaign targeting ... Continue reading

In this research article, the authors describe a quality improvement (QI) initiative aimed at reducing the unnecessary use of intravenous (IV) antihypertensive medications at a 500-bed community hospital in Texas. The QI intervention was comprised of an educational campaign targeting medical staff, nursing staff, and pharmacists, which took place sometime in November 2022. The primary outcome was the monthly utilization of IV antihypertensives, which was calculated as the number of days of therapy (DOT) per 1000 patient days (DOT/1000) per month. The secondary outcome was average length of stay per month. The outcomes were compared pre- (Jul 2022 – Oct 2022) and post-intervention (Dec 2022 – Mar 2023).

This is an important topic and I commend the authors for their work on this initiative. There is a growing body of evidence demonstrating the potential harms of overtreating severe asymptomatic hypertension. This study adds to several other recent QI initiatives with similar goals, which have utilized educational campaigns (1), informatics (2), or a combination of the two (3,4). I also applaud the authors’ use of an educational campaign, which can take significant effort to develop and implement.

In terms of results, the authors report a 47.6% reduction in the average utilization of IV antihypertensives in the four-month post-intervention period compared to the four-month pre-intervention period; however, as discussed in my feedback below, there are potential errors in the reported data and calculations. I do believe this is important work and adds to the body of existing literature. It could be appropriate for publication once these data inconsistencies, and some other issues, are addressed, but given the fundamental way these inconsistencies impact the interpretation of the results and the subsequent conclusions, it is not appropriate for acceptance prior to crucial revisions.

Major Feedback

Introduction: the references provided by the authors are out of date, with the most recent one being more than two decades old. I recommend adding more timely citations, as there have been several relevant studies published in the last few years that would better support their claims (e.g., 5-7).
Algorithm: I commend the authors for creating an easy-to-follow educational algorithm to aid in their educational efforts. Regarding the content, I have several recommendations. Obviously, the educational campaign for their initiative has already taken place and cannot be changed, but I would advocate for revising the algorithm prior to future use or publication. Specifically,
- Assessing for symptoms should be the first step of the algorithm, not the second, as treatment of hypertensive emergency should not be delayed for 30 minutes. Further, more accurate language would be to assess for “symptoms suggestive of hypertension-mediated end-organ damage”.
- In step 3 of the algorithm, consider adding other common contributing factors for hospitalized patients, including nausea, drug withdrawal, drug or alcohol intoxication, volume status, and medication side effect (e.g., corticosteroids).
- In the final step of the algorithm, I would caution against stating that gradually reducing the blood pressure “is indicated” in this setting. There is growing evidence to suggest that treating severe asymptomatic hypertension in the hospital even with oral agents may lead to harm (e.g., 6,7) and that intensification of home antihypertensive regimens on discharge may result in serious adverse events, especially among the elderly (8). At most, I would state that gradual blood pressure reduction may be indicated in certain circumstances, but this is a nuanced decision.
Results: I note several potential errors:
- The results presented in Table 1 are inconsistent with the data shared in the supplementary material. Specifically, in the first column, the DOTs for October and March are reported in the table as 247 and 117, respectively, whereas in the supplement they are reported as 274 and 177, respectively. In the second column, the “Days present” for September is reported in the table as 5732, whereas in the supplement it reads 5749. Lastly, in the third column, the DOT/1000 for September and March are reported as 45.88 and 20.18, respectively, whereas in the supplement they are reported as 45.75 and 30.53, respectively. This last error with the DOT/1000 for March is of particular concern, as it appears to demonstrate an upward trend in rates of IV antihypertensive use following the initial decrease after the intervention. The authors should explain and/or correct these inconsistencies, and address the finding of the upward trend in March in their discussion.
- In the text of the Results section, the authors state “The primary outcome was the impact on utilization of IV antihypertensives using DOT/1000. This measure showed a significant decrease in the four-month period after the intervention 25.24 (SD=3.05) compared to the four-month interval before the intervention 48.21 (SD=3.06)”. The syntax of this second sentence is confusing and it is unclear what ”this measure” is referring to. I believe the authors are comparing the average DOT/1000 for the four-month pre- and post-intervention periods, but I cannot completely replicate their calculations, regardless of whether I use the DOT/1000 values from the table, or those in from supplement. The authors should elaborate on how these values for their primary outcome were calculated (perhaps I am misunderstanding the calculation) and ensure that the math is correct.
- On the following page, under Statistical analysis, the authors report t values from a paired t-test. I would be interested to know the reasoning behind selecting a paired t-test rather than an unpaired one, as the pre/post intervention data seem independent. I tried to replicate the t-test results using the data provided but was unable to get the same values as those reported here. I do note 6 degrees of freedom listed with the t statistic, which would seem to fit more with an unpaired test.
Discussion: The authors state that “the intervention significantly reduced IV antihypertensive utilization…”. I hesitate to draw this conclusion without a) knowing the exact timing of the educational campaign, as the DOT/1000 in November was already lower than the preintervention average, and b) addressing the inconsistencies in the data, which may include a discussion of the fact that the DOT/1000 appears to have been trending back upward again as of March (assuming the data in the supplement are correct).
Discussion: there are several other limitations that should be added. First, if the initiative was comprised only of a single month of education, that the impact of the intervention would be expected to be transient. Second, the DOT/1000 calculation does not take into account the number of doses or number of patients treated on a given day, compared to measuring the number of medications orders, as done by Krouss et al. and Pasik et al. (2,3)

Minor Feedback

Methods, Ethical Considerations: The authors state “An informed consent form was used to obtain consent from participants of this project”. It is unclear who these participants were or why they were consented given that IRB approval was not needed. Please elaborate.
Methods, Project Setting: The authors mention one exclusion criteria (ED, ICU, or stroke unit), but additional inclusion/exclusion criteria would be helpful. For example, were these only adult patients?
Methods, Plan of Action: The authors state that, in addition to local hospital protocols, their algorithm was created based on “current evidence-based guidelines”. To my knowledge, while there are consensus statements from various organizations about severe asymptomatic hypertension in general (e.g., ACC/AHA), there are no evidence-based guidelines per se, especially pertaining to the management of hospitalized patients in particular. I recommend modify this statement to more accurately reflect this and add a citation to the consensus statement(s) you are referencing.
Methods, Educational sessions: More information about the educational sessions would be helpful, including when exactly they happed. Reading between the lines, they appear to have taken place sometime in November, but knowing the dates and cadence is important for interpreting the results, since, as mentioned above, the DOT/1000 for November was already lower than the preintervention average. Please also specify how the educational algorithm was used. Was this simply discussed during the educational sessions, or was it distributed and/or made accessible in some way afterward? Lastly, how will these educational efforts be carried forward in the future? If this is a one-off campaign, the impact is likely to be highly transitory and this should be addressed in the limitations section, as mentioned above.
Results, Statistical analysis: the first sentence of this section describing how the statistical analysis was conducted should appear in the Methods section, not Results.

Is the work clearly and accurately presented and does it cite the current literature?

No
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

References

1. Salman J, Salman A, Kumar S, Gjeka R, et al.: Improving the use of intravenous antihypertensive medications in the hospital setting: a quality improvement initiative for patient safety.BMJ Open Qual. 2019; 8 (4): e000626 PubMed Abstract | Publisher Full Text
2. Krouss M, Tsega S, Alaiev D, Talledo J, et al.: Reduction of Intravenous Antihypertensives through Clinical Decision Support in a Large Safety Net System.Jt Comm J Qual Patient Saf. 2023; 49 (6-7): 291-296 PubMed Abstract | Publisher Full Text
3. Pasik SD, Chiu S, Yang J, Sinfield C, et al.: Assess Before Rx: Reducing the Overtreatment of Asymptomatic Blood Pressure Elevation in the Inpatient Setting.J Hosp Med. 2019; 14 (3): 151-156 PubMed Abstract | Publisher Full Text
4. Jacobs ZG, Najafi N, Fang MC, Prasad PA, et al.: Reducing Unnecessary Treatment of Asymptomatic Elevated Blood Pressure with Intravenous Medications on the General Internal Medicine Wards: A Quality Improvement Initiative.J Hosp Med. 2019; 14 (3): 144-150 PubMed Abstract | Publisher Full Text
5. Mohandas R, Chamarthi G, Bozorgmehri S, Carlson J, et al.: Pro Re Nata Antihypertensive Medications and Adverse Outcomes in Hospitalized Patients: A Propensity-Matched Cohort Study.Hypertension. 2021; 78 (2): 516-524 PubMed Abstract | Publisher Full Text
6. Rastogi R, Sheehan MM, Hu B, Shaker V, et al.: Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions.JAMA Intern Med. 2021; 181 (3): 345-352 PubMed Abstract | Publisher Full Text
7. Anderson TS, Herzig SJ, Jing B, Boscardin WJ, et al.: Clinical Outcomes of Intensive Inpatient Blood Pressure Management in Hospitalized Older Adults.JAMA Intern Med. 2023; 183 (7): 715-723 PubMed Abstract | Publisher Full Text
8. Anderson TS, Jing B, Auerbach A, Wray CM, et al.: Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge.JAMA Intern Med. 2019; 179 (11): 1528-1536 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Inpatient hypertension

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Zachary G. Jacobs, Oregon Health & Science University, Portland, USA
Ingrid Prkacin, University of Zagreb, Zagreb, Croatia

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15 Dec 2023 | for Version 1

Ingrid Prkacin, School of Medicine, University of Zagreb, Zagreb, Croatia

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Approved With Reservations

This article describes the results of a quality improvement project focusing on the reduction of intravenous antihypertensive medication use following the creation of an algorithm for the management of severe (grade III) hypertension in the emergency department and staff education.
While the topic is interesting and important, there are several questions that require answering before the article is ready for publication.
1. In the "Ethical considerations" part of the "Methods" section, it is stated that the project involved the review of de-identified pharmacy data and that no patient records were accessed. It also states that an informed consent form was used to obtain consent from the participants. Who were the participants that were required to give consent if no patient records were accessed, and the study was based on aggregated, de-identified pharmacy data?
2. In the "Plan of action" part of the "Methods" section, the authors mention that the algorithm was created based on current evidence-based guidelines and local hospital protocols but cites no such guidelines. Which guidelines were used and from what societies? Please also provide citations for these guidelines.
3. The "Educational sessions" part of the "Methods" section should be expanded and explained in more detail, outlining the curriculum used, number of sessions, topics of each session etc. (this can be provided as an Appendix or Supplemental Material) in order to make the intervention replicable in other interested institutions.
4. In "Table 1" of the "Results" section, it is stated that the DOT/1000 for March 2023 was 20.18, while in the "Underlying material" data, page 6, it is stated that the DOT/1000 for March 2023 was 30.53. Please explain this discrepancy.
5. More citations should be added, especially to the "Discussion" section, which contains none.
6. Which oral antihypertensive medications were used in place of the intravenous ones? There should be pharmaceutical data on the usage of those. Is there a trend of an increase in the use of oral antihypertensive medications in the observed period following the implementation of the algorithm?
7. The references should be of a more recent date. Also, similar interventions implemented by other authors should be discussed and presented in the "Discussion" section (for example, the study by Grassi et al. cited below).

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

References

1. Grassi D, O'Flaherty M, Pellizzari M, Bendersky M, et al.: Hypertensive urgencies in the emergency department: evaluating blood pressure response to rest and to antihypertensive drugs with different profiles.J Clin Hypertens (Greenwich). 2008; 10 (9): 662-7 PubMed Abstract | Publisher Full Text

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Arterial Hypertension, Chronic Kidney Disease, Emergency Medicine, Nephrology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

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Reviewer Report

7 Views

18 Oct 2023 | for Version 1

Zachary G. Jacobs, Oregon Health & Science University, Portland, Oregon, USA

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Not Approved

In this research article, the authors describe a quality improvement (QI) initiative aimed at reducing the unnecessary use of intravenous (IV) antihypertensive medications at a 500-bed community hospital in Texas. The QI intervention was comprised of an educational campaign targeting medical staff, nursing staff, and pharmacists, which took place sometime in November 2022. The primary outcome was the monthly utilization of IV antihypertensives, which was calculated as the number of days of therapy (DOT) per 1000 patient days (DOT/1000) per month. The secondary outcome was average length of stay per month. The outcomes were compared pre- (Jul 2022 – Oct 2022) and post-intervention (Dec 2022 – Mar 2023).

This is an important topic and I commend the authors for their work on this initiative. There is a growing body of evidence demonstrating the potential harms of overtreating severe asymptomatic hypertension. This study adds to several other recent QI initiatives with similar goals, which have utilized educational campaigns (1), informatics (2), or a combination of the two (3,4). I also applaud the authors’ use of an educational campaign, which can take significant effort to develop and implement.

In terms of results, the authors report a 47.6% reduction in the average utilization of IV antihypertensives in the four-month post-intervention period compared to the four-month pre-intervention period; however, as discussed in my feedback below, there are potential errors in the reported data and calculations. I do believe this is important work and adds to the body of existing literature. It could be appropriate for publication once these data inconsistencies, and some other issues, are addressed, but given the fundamental way these inconsistencies impact the interpretation of the results and the subsequent conclusions, it is not appropriate for acceptance prior to crucial revisions.

Major Feedback

Introduction: the references provided by the authors are out of date, with the most recent one being more than two decades old. I recommend adding more timely citations, as there have been several relevant studies published in the last few years that would better support their claims (e.g., 5-7).
Algorithm: I commend the authors for creating an easy-to-follow educational algorithm to aid in their educational efforts. Regarding the content, I have several recommendations. Obviously, the educational campaign for their initiative has already taken place and cannot be changed, but I would advocate for revising the algorithm prior to future use or publication. Specifically,
- Assessing for symptoms should be the first step of the algorithm, not the second, as treatment of hypertensive emergency should not be delayed for 30 minutes. Further, more accurate language would be to assess for “symptoms suggestive of hypertension-mediated end-organ damage”.
- In step 3 of the algorithm, consider adding other common contributing factors for hospitalized patients, including nausea, drug withdrawal, drug or alcohol intoxication, volume status, and medication side effect (e.g., corticosteroids).
- In the final step of the algorithm, I would caution against stating that gradually reducing the blood pressure “is indicated” in this setting. There is growing evidence to suggest that treating severe asymptomatic hypertension in the hospital even with oral agents may lead to harm (e.g., 6,7) and that intensification of home antihypertensive regimens on discharge may result in serious adverse events, especially among the elderly (8). At most, I would state that gradual blood pressure reduction may be indicated in certain circumstances, but this is a nuanced decision.
Results: I note several potential errors:
- The results presented in Table 1 are inconsistent with the data shared in the supplementary material. Specifically, in the first column, the DOTs for October and March are reported in the table as 247 and 117, respectively, whereas in the supplement they are reported as 274 and 177, respectively. In the second column, the “Days present” for September is reported in the table as 5732, whereas in the supplement it reads 5749. Lastly, in the third column, the DOT/1000 for September and March are reported as 45.88 and 20.18, respectively, whereas in the supplement they are reported as 45.75 and 30.53, respectively. This last error with the DOT/1000 for March is of particular concern, as it appears to demonstrate an upward trend in rates of IV antihypertensive use following the initial decrease after the intervention. The authors should explain and/or correct these inconsistencies, and address the finding of the upward trend in March in their discussion.
- In the text of the Results section, the authors state “The primary outcome was the impact on utilization of IV antihypertensives using DOT/1000. This measure showed a significant decrease in the four-month period after the intervention 25.24 (SD=3.05) compared to the four-month interval before the intervention 48.21 (SD=3.06)”. The syntax of this second sentence is confusing and it is unclear what ”this measure” is referring to. I believe the authors are comparing the average DOT/1000 for the four-month pre- and post-intervention periods, but I cannot completely replicate their calculations, regardless of whether I use the DOT/1000 values from the table, or those in from supplement. The authors should elaborate on how these values for their primary outcome were calculated (perhaps I am misunderstanding the calculation) and ensure that the math is correct.
- On the following page, under Statistical analysis, the authors report t values from a paired t-test. I would be interested to know the reasoning behind selecting a paired t-test rather than an unpaired one, as the pre/post intervention data seem independent. I tried to replicate the t-test results using the data provided but was unable to get the same values as those reported here. I do note 6 degrees of freedom listed with the t statistic, which would seem to fit more with an unpaired test.
Discussion: The authors state that “the intervention significantly reduced IV antihypertensive utilization…”. I hesitate to draw this conclusion without a) knowing the exact timing of the educational campaign, as the DOT/1000 in November was already lower than the preintervention average, and b) addressing the inconsistencies in the data, which may include a discussion of the fact that the DOT/1000 appears to have been trending back upward again as of March (assuming the data in the supplement are correct).
Discussion: there are several other limitations that should be added. First, if the initiative was comprised only of a single month of education, that the impact of the intervention would be expected to be transient. Second, the DOT/1000 calculation does not take into account the number of doses or number of patients treated on a given day, compared to measuring the number of medications orders, as done by Krouss et al. and Pasik et al. (2,3)

Minor Feedback

Methods, Ethical Considerations: The authors state “An informed consent form was used to obtain consent from participants of this project”. It is unclear who these participants were or why they were consented given that IRB approval was not needed. Please elaborate.
Methods, Project Setting: The authors mention one exclusion criteria (ED, ICU, or stroke unit), but additional inclusion/exclusion criteria would be helpful. For example, were these only adult patients?
Methods, Plan of Action: The authors state that, in addition to local hospital protocols, their algorithm was created based on “current evidence-based guidelines”. To my knowledge, while there are consensus statements from various organizations about severe asymptomatic hypertension in general (e.g., ACC/AHA), there are no evidence-based guidelines per se, especially pertaining to the management of hospitalized patients in particular. I recommend modify this statement to more accurately reflect this and add a citation to the consensus statement(s) you are referencing.
Methods, Educational sessions: More information about the educational sessions would be helpful, including when exactly they happed. Reading between the lines, they appear to have taken place sometime in November, but knowing the dates and cadence is important for interpreting the results, since, as mentioned above, the DOT/1000 for November was already lower than the preintervention average. Please also specify how the educational algorithm was used. Was this simply discussed during the educational sessions, or was it distributed and/or made accessible in some way afterward? Lastly, how will these educational efforts be carried forward in the future? If this is a one-off campaign, the impact is likely to be highly transitory and this should be addressed in the limitations section, as mentioned above.
Results, Statistical analysis: the first sentence of this section describing how the statistical analysis was conducted should appear in the Methods section, not Results.

Is the work clearly and accurately presented and does it cite the current literature?

No
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Partly
Are the conclusions drawn adequately supported by the results?

Partly

References

1. Salman J, Salman A, Kumar S, Gjeka R, et al.: Improving the use of intravenous antihypertensive medications in the hospital setting: a quality improvement initiative for patient safety.BMJ Open Qual. 2019; 8 (4): e000626 PubMed Abstract | Publisher Full Text
2. Krouss M, Tsega S, Alaiev D, Talledo J, et al.: Reduction of Intravenous Antihypertensives through Clinical Decision Support in a Large Safety Net System.Jt Comm J Qual Patient Saf. 2023; 49 (6-7): 291-296 PubMed Abstract | Publisher Full Text
3. Pasik SD, Chiu S, Yang J, Sinfield C, et al.: Assess Before Rx: Reducing the Overtreatment of Asymptomatic Blood Pressure Elevation in the Inpatient Setting.J Hosp Med. 2019; 14 (3): 151-156 PubMed Abstract | Publisher Full Text
4. Jacobs ZG, Najafi N, Fang MC, Prasad PA, et al.: Reducing Unnecessary Treatment of Asymptomatic Elevated Blood Pressure with Intravenous Medications on the General Internal Medicine Wards: A Quality Improvement Initiative.J Hosp Med. 2019; 14 (3): 144-150 PubMed Abstract | Publisher Full Text
5. Mohandas R, Chamarthi G, Bozorgmehri S, Carlson J, et al.: Pro Re Nata Antihypertensive Medications and Adverse Outcomes in Hospitalized Patients: A Propensity-Matched Cohort Study.Hypertension. 2021; 78 (2): 516-524 PubMed Abstract | Publisher Full Text
6. Rastogi R, Sheehan MM, Hu B, Shaker V, et al.: Treatment and Outcomes of Inpatient Hypertension Among Adults With Noncardiac Admissions.JAMA Intern Med. 2021; 181 (3): 345-352 PubMed Abstract | Publisher Full Text
7. Anderson TS, Herzig SJ, Jing B, Boscardin WJ, et al.: Clinical Outcomes of Intensive Inpatient Blood Pressure Management in Hospitalized Older Adults.JAMA Intern Med. 2023; 183 (7): 715-723 PubMed Abstract | Publisher Full Text
8. Anderson TS, Jing B, Auerbach A, Wray CM, et al.: Clinical Outcomes After Intensifying Antihypertensive Medication Regimens Among Older Adults at Hospital Discharge.JAMA Intern Med. 2019; 179 (11): 1528-1536 PubMed Abstract | Publisher Full Text

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Inpatient hypertension

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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[1] 1. Cherney D, Straus S: Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature. Gen. Intern. Med. 2002; 17(12): 937–945. PubMed Abstract | Publisher Full Text | Free Full Text

[2] 2. Kitiyakara C, Guzman N: Malignant hypertension and hypertensive emergencies. J. Am. Soc. Nephrol. 1998; 9: 133–142. Publisher Full Text

[3] 3. O’Mailia JJ, Sander GE, Giles TD: Nifedipine-associated myocardial ischemia or infarction in the treatment of hypertensive urgencies. Ann. Intern. Med. 1987; 107(2): 185. Publisher Full Text

[4] 4. Grossman E, Messerli FH, Grodzicki T, et al.: Should a moratorium be placed on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies. JAMA. 1996; 276(16): 1328–1331. PubMed Abstract | Publisher Full Text

[5] 5. Zeller KR, Von Kuhnert L, Matthews C: Rapid reduction of severe asymptomatic hypertension: a prospective, controlled trial. Arch. Intern. Med. 1989; 149(10): 2186–2189. PubMed Abstract | Publisher Full Text

[6] 6. Alnazeer M: Implementing a Quality Improvement Initiative for Reducing Intravenous Antihypertensive Utilization in The Hospital Setting Improving Patient Safety Without Prolonging Hospital Stay. [Dataset]. figshare. 2023. Publisher Full Text

Implementing a quality improvement initiative for reducing intravenous antihypertensive utilization in the hospital setting: Improving patient outcomes without prolonging hospital stay

Abstract

Keywords

Introduction

Figure 1. The algorithm used to assist in managing severe hypertension in the hospital setting.

Methods

Ethical considerations

Project setting

Data collection

Outcome measure

Plan of action

Educational sessions

Monitoring

Data analysis

Results

Table 1. Outline utilization data of IV hydralazine and labetalol over the duration from July 2022 to March 2023.

Figure 2. Days of therapy/1000 patient days (DOT/1000) for IV Hydralazine and Labetalol and average length of stay in days pre-July–October 2022) and post-December 2022–March 2023 implementation of the quality improvement initiative in November 2022.

Statistical analysis

Discussion

Conclusions

Consent

Data availability

Underlying data

References

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