Reduction of Intravenous Antihypertensives through Clinical Decision Support in a Large Safety Net System

• Published in: Joint Commission journal on quality and patient safety Vol. 49; no. 6-7; p. 291
• Main Authors: Krouss, Mona, Tsega, Surafel, Alaiev, Daniel, Talledo, Joseph, Chandra, Komal, Manchego, Peter Alarcon, Zaurova, Milana, Shin, Dawi, Garcia, Mariely, Cho, Hyung J
• Format: Journal Article
• Language: English
• Published: Netherlands 01.06.2023
• Subjects: Antihypertensive Agents - adverse effects; Blood Pressure; Decision Support Systems, Clinical; Humans; Hydralazine - adverse effects; Hypertension - drug therapy; Labetalol - adverse effects
• DOI: 10.1016/j.jcjq.2023.03.001

Asymptomatic severe hypertension (also known as hypertensive urgency) is frequently encountered in the hospital. Previous evidence suggests that management with one-time doses of intravenous (IV) antihypertensives may increase adverse events. Despite this, single-dose treatment remains common in the emergency department and inpatient settings. This quality initiative was launched at New York City Health + Hospitals, the largest safety net hospital system in the United States. The initiative involved two changes to electronic orders for IV hydralazine and IV labetalol: a nonintrusive advisory statement within the order instructions and a mandatory requirement to document the indication for IV antihypertensive use. This initiative took place from November 2021 to October 2022. Of the indications selected for IV antihypertensive orders, 60.7% were for hypertensive emergency, 15.3% were for patients who were strictly NPO, 21.2% were for other, and 2.8% selected more than one indication. For ED-only encounters, aggregate IV hydralazine and IV labetalol orders per 1,000 patient encounters were 2.53 preintervention and 1.55 postintervention (38.7% reduction, p < 0.001). For inpatient encounters, aggregate IV hydralazine and IV labetalol orders per 1,000 patient-days were 18.25 preintervention and 15.81 postintervention (13.4% reduction, p < 0.001). Similar trends were observed for individual orders of IV hydralazine and IV labetalol. There were significant reductions in 7 of the 11 hospitals in inpatient administration of aggregate IV hydralazine and labetalol orders per 1,000 patient-days. This quality improvement initiative successfully reduced unnecessary IV antihypertensive use in an 11-hospital safety net system.