Acute severe hypertension in the emergency and acute medicine departments: developing a same-day emergency care (SDEC) hypertension pathway

Abstract

Introduction: Hypertension affects approximately one in three adults in England; however, ~50% are either untreated or uncontrolled.¹ The numbers of those presenting to hospital with hypertension is increasing and there is great variability in how they are managed.² The reality of Operational Pressures Escalation Level (OPEL) 4 becoming the norm across NHS Trusts highlights the importance of NHS strategies, such as SAMEDAY, and novel collaborative initiatives in managing this demand.³ An initial audit of a tertiary hospital emergency department (ED) found that, among patients whose primary presenting issue was a BP >160/90 mmHg (without concern for a hypertensive emergency), 41% had an ECG, U&Es and urine dip to screen for hypertensive mediated organ damage (HMOD), 39.5% had a therapeutic intervention for raised blood pressure and 9.2% were admitted to hospital due to hypertension via the Acute Medical Take. Following a series of initiatives in the ED, the proportion who had HMOD screening improved to 60%. However, there was still an unmet need in appropriate follow-up for patients with acute severe hypertension who required prompt investigation and follow-up. This led to the development of a same-day emergency care (SDEC) hypertension pathway to provide admission avoidance, reduce ED re-attendances and provide a bridge between acute services, primary care and specialist outpatient hypertension clinics. Material(s) and Method(s): In collaboration with the acute medicine, emergency and clinical pharmacology and therapeutics (CPT) departments, we developed a SDEC hypertension pathway for acute follow-up for patients presenting to ED with acute severe hypertension. Any patient presenting to ED or the Acute Medical Take during the previous week with BP either >180/110 mmHg or >160/100 mmHg with new HMOD was eligible for referral to the pathway. As part of a weekly 'one-stop' service, patients were comprehensively reviewed by a CPT specialty registrar, embedded in SDEC, to evaluate for secondary causes of hypertension, and HMOD and develop a treatment regimen. After evaluation, patients were either discharged to primary care with a comprehensive plan, including advice on lifestyle and home monitoring, or referred onwards to the specialist hypertension clinic for follow-up. Result(s): Data collected from the first 36 patients seen in the SDEC hypertension pathway revealed that 64% of patients had additional HMOD or a secondary cause of hypertension. A comparative sample of ED patients pre-pathway, who would have met criteria for referral to the SDEC hypertension pathway, showed there was an approximately two times greater reduction in BP compared with standard care (discharge from ED directly back to GP) on remote follow-up of BP in the community (Figs 1 and 2); within a 6-month period from initial ED attendance, there were almost three times fewer ED re-attendances in the post- compared with the pre-SDEC cohort, with fewer converting to an acute admission (Fig 2). Conclusion(s): These preliminary findings show the positive effect of having acute subspecialty services working in conjunction with SDEC to provide alternatives pathways to admission, resulting in improved patient care and reductions in re-admission and morbidity. Further data to show long term effects will be required. Copyright © 2025