Health Care Guideline:
Worksite Hypertension
General Implementation July 1998
Copyright © 1998 by Institute for Clinical Systems Integration
The information contained in this web site, including the ICSI Health Care
Guidelines ("ICSI Guidelines"), is intended primarily for health
professionals and the following expert audiences:
Neither the ICSI Guidelines nor any other information in this web site should be construed as medical advice or medical opinion related to any specific facts or circumstances. If you are not one of the expert audiences listed above you are urged to consult a health care professional regarding your own situation and any specific medical questions you may have. In addition, you should seek assistance from a health care professional in interpreting the materials in this web site and applying the materials in your individual case.
The ICSI Guidelines contained in this web site are designed to assist clinicians by providing an analytical framework for the evaluation and treatment of patients, and are not intended either to replace a clinician's judgment or to establish a protocol for all patients with a particular condition. An ICSI Guideline rarely will establish the only approach to a problem.
The ICSI Guidelines may be downloaded by any individual or organization. Copies of the ICSI Guidelines may be distributed by any organization to the organization's employees but, except as provided below, may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Integration, Inc. If the ICSI Guidelines are downloaded by a legally constituted medical group, they may be used by the medical group in any of the following ways:
All other copyright rights in the ICSI Guidelines are reserved by the Institute for Clinical Systems Integration, Inc. The Institute for Clinical Systems Integration, Inc. assumes no liability for any adaptations or revisions or modifications made to the ICSI Guidelines.
Work Group Leader
Cathy Peterson, LPN, General Mills
Benefits Personnel
Becky Thyken, Rosemount Aerospace
Ruth Mell, Dayton Hudson Corporation
Jennifer Bichsel, Ceridian
Jack Stoltzfus, PhD, 3M
Clinic Nurse
Linda Pietz, RN, Institute for Research and Education, HealthSystem
Minnesota
Health Education
Maureen Convey, HealthPartners
Physicians
Robb Campbell, MD, MPH, 3M
Diane Davies, MD, AMS, Schneider (USA), Pfizer
David Gregg, MD, HealthPartners
Thomas Jetzer, MD, Northern States Power
Worksite Nurse
Cathy Peterson, LPN, General Mills
Measurement Advisor
Jane Gendron, ICSI
Facilitator
Linda Pietz, RN, Institute for Research and Education, HealthSystem
Minnesota
BHCAG employees and their dependents (optional).
Priority Aims for Worksites When Using This Guideline
1. Increase hypertension education.
Possible measures of accomplishing this aim:
a. Number of worksite sponsored activities within a 12 month period directed towards hypertension education.
b. Percentage of employees reporting receipt of hypertension education at the worksite.
c. Percentage of employees and adult dependents reporting receiving worksite originated hypertension education within the past 12 months.
d. Percentage of employees receiving a hypertension risk appraisal tool.
2. Increase opportunities for blood pressure screening.
Possible measures of accomplishing this aim:
a. Number of blood pressure screening events in a 12 month period.
b. Percentage of employees who report having blood pressure taken within the last year.
c Percentage of employees and adult dependents reporting blood pressure screening within the past 24 months.
3. Improve monitoring and follow-up activities.
Possible measures of accomplishing this aim:
a. Percentage of staff trained to take a standardized blood pressure measurement.
b. Percentage of persons whose blood pressure screening results suggest a Stage 2 category of illness who are seen for further evaluation within 1 month.
c. Number of employees who receive onsite counseling about blood pressure control.
d. Number of life style choice incentives made available to employees (low sodium cafeteria food, support for smoking cessation, etc.).
e. Number of employees identified with hypertension who report access to blood pressure monitoring at work, home or community.
Clinical Algorithm & Annotations
1. Employee/Dependents of BHCAG Member Company
This Buyers Health Care Action Group worksite guideline should be implemented for BHCAG member employees. Dependents may be included in guideline activities at the discretion of the employer.
Back to Contents
Back to Algorithm Annotation List
2. Preplacement Physical Examination
A preplacement physical examination which includes blood pressure measurement, if utilized by the company, may serve as an alternate entry point into the guideline.
Back to Contents
Back to Algorithm Annotation List
3. Education/Information on Hypertension
Employers can take cost-effective steps to help reduce the incidence of hypertension in the work place. They can educate the work force and their dependents to recognize the risk factors for and the effects of hypertension and to recognize the need for life-style changes or proper medical evaluation.
Risk factors that may contribute to increases in blood pressure include:
Other cardiovascular risk factors include cigarette smoking, elevated cholesterol, diabetes, and family history.
Screening programs that include blood pressure testing and health risk appraisals can uncover risk factors before employees develop any symptoms or warning signs.
The type of education that is available at the worksite is dependent on the workforce population, location, makeup and type of facilities available. Each employer should annually select and conduct a minimum of three methods of education appropriate to its own circumstances.
Suggested methods of delivery:
Back to Contents
Back to Algorithm Annotation List
4. Employee/Dependent Volunteers to Participate
Participation in hypertension screening should be voluntary and should be available for all employees and dependents. Since this guideline deals with medical information not necessarily related to an individual's ability to perform his or her position, employees must be given a choice as to the level of their participation.
Each worksite should do an annual promotion of blood pressure screening either on or offsite. The worksite should select the most appropriate method of screening for its own circumstances.
Options and opportunities for blood pressure screening include:
All blood pressure readings must be kept strictly confidential unless the employee has given his or her consent to release the information. In addition, aggregate, anonymous reporting may be reviewed by employers to assist in developing and implementing targeted education.
Back to Contents
Back to Algorithm Annotation List
5. Take Standardized Blood Pressure Measurement
For consistency, accuracy and reliability in blood pressure measurement by professionals conducting blood pressure screenings see Annotation Appendix I, "Standards for Blood Pressure Measurement" (taken from the ICSI Preventive Services for Adults guideline).
If blood pressure machines are used, clearly marked and easy to follow instructions should be posted on or near each machine. The machines should be properly calibrated and maintained according to the manufacturer's recommendations or American Heart Association recommendations for regular calibration.
Back to Contents
Back to Algorithm Annotation List
6. Employee has Blood Pressure > 139 Systolic, or > 89 Diastolic, or is Diagnosed with Hypertension?
Employees without elevated blood pressure should be provided information on hypertension and further opportunities for blood pressure measurement at the recommended intervals.
Employees with an elevated blood pressure or a confirmed diagnosis of hypertension are defined in the following terms:
Classification of Blood Pressure for Adults Age 18 Years or Older
*
With Follow-up Recommendations
| Category Normal ** High Normal Hypertension *** Stage 1 (Mild) Stage 2 (Moderate) Stage 3 (Severe) Stage 4 (Very Severe) |
Systolic (mm Hg) < 130 130-139 140-159 160-179 180-209 >210 |
Diastolic (mm Hg) < 85 85-89 90-99 100-109 110-119 >120 |
Follow-up Recommended**** Recheck within 2 years Recheck within 1 year***** Confirm within 2 months Evaluate or refer promptly to source of care within 1 month Evaluate or refer to source or care within 1 week Evaluate or refer to source of care immediately |
* Not taking antihypertensive drugs and not acutely
ill. When systolic and diastolic pressure fall into different categories,
the higher category should be selected to classify the individual's blood
pressure status. For instance, 160/92 should be classified as Stage 2,
and 180/120 should be classified as Stage 4. Isolated systolic hypertension
(ISH) is defined as SBP 140 mm Hg and DBP
90 mm Hg and staged appropriately (e.g., 170/85 mm Hg is defined as Stage
2 ISH).
** Optimal blood pressure with respect to cardiovascular risk is SBP < 120 mm Hg and DBP < 80 mm Hg. However, unusually low reading should be evaluated for clinical significance.
*** Based on the average of two or more readings taken at each of two or more visits following an initial screening.
Note: In addition to classifying stages of hypertension based on average blood pressure levels, the clinician should specify presence or absence of target-organ disease and additional risk factors. For example, a patient with diabetes and a blood pressure of 142/94 mm Hg plus left ventricular hypertrophy should be classified as "Stage 1 hypertension with target-organ disease (left ventricular hypertrophy) and with another major risk factor (diabetes)." This specificity is important for risk classification and management.
**** The scheduling of follow-up should be modified by reliable information about past blood pressure measurements, other cardiovascular risk factors or target-organ disease.
***** Consider providing advice about lifestyle modifications.
Back to Contents
Back to Algorithm Annotation List
7. Blood Pressure > 209 Systolic, or > 119 Diastolic?
Back to Contents
Back to Algorithm Annotation List
8. Targeted Education/Urgent Referral
Employees whose blood pressure places them in imminent danger of morbidity or mortality (BP > 209 systolic and/or > 119 diastolic) should be immediately referred for definitive therapy. Follow-up should be conducted in accordance with the ICSI Hypertension Diagnosis and Treatment guideline.
Back to Contents
Back to Algorithm Annotation List
9. Blood Pressure Between 139 and 210 Systolic, or 89 and 120 Diastolic?
Back to Contents
Back to Algorithm Annotation List
10. Targeted Education/Non-Urgent Referral
Employees whose blood pressure is elevated but not immediately dangerous (BP between 139 and 210 systolic and/or between 89 and 120 diastolic) should be referred to their provider for confirmation and follow-up within one week.
Employees with a history of hypertension whose blood pressure is acceptable during screening need no referral, but should be provided with continuing opportunities for further monitoring.
Back to Contents
Back to Algorithm Annotation List
11. Ongoing Worksite Monitoring Activities
As part of the ongoing treatment of hypertension, once the hypertension is stable the employee should monitor his or her blood pressure frequently through home monitoring or through a health care professional. Since the major reason for inadequate blood pressure control is noncompliance with ongoing therapy, making confidential and convenient monitoring available at the worksite may result in a better chance of successful blood pressure control.
The type of ongoing monitoring and follow-up that is available at the worksite is dependent on the work force population, location, and makeup as well as the type of facilities available. Each worksite should select the most appropriate means of monitoring for its own circumstances, realizing the type of monitoring could change over time.
Methods of Ongoing Blood Pressure Monitoring and Follow-up Include:
Each organization should evaluate ways in which it can facilitate and elicit employee follow-through with ongoing therapy. Each worksite should select the most appropriate means for its circumstances.
Methods for facilitating and providing incentives for ongoing monitoring include:
Back to Contents
Back to Algorithm Annotation List
Annotation Appendix I - Standards for Blood Pressure Measurement *
Accurate, reproducible blood pressure measurement is important to correctly classify blood pressure. Inconsistencies may result from using defective equipment and not standardizing the technique. Review the following steps and the accompanying rationale. Based on surveys that show the variability of BP measurement, training sessions should be arranged by your medical facility or employer.
* These standards are consistent with AHA and NHLBI recommendations.
Selecting Equipment:
Use mercury manometer or a recently calibrated aneroid manometer with the center of the mercury column or aneroid dial at eye level.
Select appropriate cuff size. The width of the bladder should be 40% of the arm circumference and the length of the bladder should encircle at least 80% of the arm.
Use the bell of the stethoscope. Ideally the bell should be placed above the medial epicondyle and medial to the biceps tendon. (Brachial artery).
Rationale:
If the meniscus of the Hg or aneroid gauge is not level with your vision, a reading may be read as too high or too low.
Too small a cuff will give falsely high readings. Too large a cuff may rarely give a false low reading but with less clinical significance.
The stethoscope bell is designed to listen to low-pitched sounds. The early and late blood pressure sounds are low-pitched.
Preparing the Patient:
The patient should avoid eating, smoking, caffeine, exercise, and drinking alcohol one-half to one hour before blood pressure measurement.
Have the patient sit quietly for a period of rest with both feet flat on the floor and back supported prior to measurement.
No clothing should be between the blood pressure cuff and the arm. Place the center of the cuff's bladder over the brachial artery on the upper arm.
Use the patient's same arm for blood pressure readings and record arm and cuff size used.
The patient's arm should be supported or allowed to rest on a solid surface so the inner aspect of the bend of the elbow is level with the heart.
Rationale:
Readings will vary after exercise, eating, smoking, drinking alcohol or having caffeine (e.g. differences of 5-15 mm Hg with 150 mg caffeine within 15 minutes).
Any change in posture or activity causes blood pressure to change. Some patients may experience an alerting reaction initially.
Extra noise from the bell of the stethoscope rubbing against clothing could cause a false blood pressure reading. Failure to center the cuff can result in a falsely high reading.
This allows for consistency and better comparison.
The difference between lower and higher positions of the arm can cause differences in measurements of as much as 10 mm Hg systolic and diastolic. For every cm the cuff sits above or below heart level, the blood pressure varies by 0.8 mm Hg. If the patient's arm is tense, measurement can vary by up to 15 mm Hg (systolic more than diastolic).
Taking an Initial Measurement:
Secure the blood pressure cuff evenly and snugly around the arm, 1 to 1-1/2 inches above the antecubital space (at the elbow). Center the bladder (inflatable bag) over the brachial artery.
Initially perform a palpatory estimate of systolic pressure. Wait 15-30 seconds before taking the auscultatory reading.
Inflate the cuff quickly to 30 mm Hg above the palpatory blood pressure.
Deflate bladder at 2-3 mm Hg per second.
Record the first of at least two consecutive sounds as the systolic. Diastolic is identified by the last sound heard. If blood pressure is normal (systolic <140 and diastolic < 90), inform the patient.
Helpful hint: If the tones are difficult to hear, confirm brachial artery location by palpitation; then elevate arm for 15 seconds to drain the veins. Inflate the cuff, with arm still overhead, to 60 mm Hg above palpatory blood pressure. Then lower arm and repeat auscultation.
Rationale:
A loose blood pressure cuff may balloon in the center, decreasing the effective width of the cuff. Since pressure transmitted through larger tissue bulk requires more external pressure to compress the underlying artery, a falsely higher lever of systolic and diastolic pressure may be heard.
This step provides knowledge of the range of the systolic pressure. An auscultatory gap (absence of sound for 20-40 mm Hg) occurs in 5% of hypertensives. The estimate will help to avoid incorrectly recording the systolic below the gap.
Inflating the cuff too high can cause pain and result in a falsely high reading.
If the pressure is released too quickly, you could record the systolic blood pressure falsely low as the first systolic tap is missed and the diastolic falsely high. If you deflate too slowly, you could record the diastolic falsely high.
The last sound heard is easier than muffling for observers to accurately record. In some patients, for example, children or pregnant women, sounds are heard to near 0. In these cases, record both muffling and 0, e.g. 150/80/0. The muffling value is then considered the diastolic pressure.
Confirming Initial Elevation:
If blood pressure is elevated and the patient had initially waited quietly for five minutes, repeat blood pressure in 1-2 minutes. Record both measurements, and inform the patient.
If blood pressure is elevated but the patient had not initially waited quietly for five minutes, now allow for a five minute rest. Re-measure blood pressure and record it as the first reading, If this blood pressure is still elevated, repeat the measurement in 1-2 minutes, record it as the second measurement, and inform the patient.
Rationale:
Because blood pressure normally varies up to 10 mm Hg it is necessary to take two readings to obtain the most accurate present blood pressure.
A time interval of 1-2 minutes between cuff inflations is necessary to reduce forearm engorgement.
Back to Contents
Back to Algorithm Annotation List
Grade A: Conclusion based on a randomized, controlled trial that has been published in a peer-reviewed journal.
Grade B: Conclusion based on one of the following study types published in a peer-reviewed journal (but not on a randomized, controlled trial):
Grade C: Conclusion based on one of the following (but not on any studies of the types mentioned above):
Guidelines obtained from the Agency for Health Care Policy and Research
(AHCPR) or other sources, position statements, panel consensus statements
from the National Institutes of Health (NIH) or elsewhere, review articles,
and textbook chapters that cite primary evidence are not assigned a grade
because they are not primary evidence. The individual studies cited in
such secondary sources can be graded according to the categories presented
above.
Released in July 1998 for General Implementation.
Other Guidelines Referenced Within This Guideline
Instructions
for Downloading PDF Version of This Guideline
Click here to download the
full version of this Guideline in PDF format. You will need ADOBE Acrobat
reader to view the file. The reader may be found here.
Back to Contents
Back to List of Guidelines