Blood pressure in hospitalized patients

Blood pressure measurement is one of the most frequently performed medical procedures in ambulatory medicine but also in hospitalized patients. In most clinical wards around the world, blood pressure is measured several times a day in every patient and values are carefully reported on the medical charts. Historically, blood pressure was measured so often not to detect high blood pressure or diagnose arterial hypertension but essentially as a vital sign that should provide information on the stability of the cardiovascular system and be a potential predictor of clinical events that might happen during the patient's hospitalization [1]. The importance of blood pressure monitoring in emergency wards or ICUs is undeniable and will not be discussed here. However, the clinical relevance of measuring blood pressure again and again in patients admitted in medical or surgical wards is regularly questioned. The first common criticism relates to the quality of blood pressure measurements performed by nurses and physicians in the context of the hospital. There have been several publications on the accuracy of blood pressure measuring devices and on the protocol used to measure blood pressure, if any [2–4]. In fact, it seems rather obvious that most hospitals do not use a standardized operational procedure to measure blood pressure in admitted patients and hence blood pressure values are acquired in many different conditions (sitting, standing, supine and so on). Interpretation of such measurements would be very difficult unless extreme values are obtained. In fact, it is rather surprising that very few studies have actually assessed the quality of blood pressure measurements in a large group of hospitalized patients. This is the merit of the study of Manzoli et al.[5] published in this issue of the Journal of Hypertension. The multicentric observational study conducted by Manzoli et al.[5] was performed in 14 public hospitals in Italy and enrolled 1334 patients hospitalized for an ordinary admission. Emergencies and ICUs and patients with psychiatric disorders were not included. The assessment of the blood pressure measuring procedure was conducted by a trained nurse, who interviewed each patient within a couple of hours after the procedure was done and filled a 15 items questionnaire containing the recommendations made by international hypertension societies. As expected, in hospital, blood pressure was measured essentially by nurses or nurse students (76%) and only infrequently by physicians or medical students. The results of this evaluation are striking: the procedure is rarely explained to the patients and only 50% of patients were resting for 5 min before the measurement. Furthermore, blood pressure was measured only once in more than 80% of the cases and almost never on both arms at least once during their stay and a large cuff for obese patients was infrequently available. Taken together, the 15 recommended items were never followed and only in one-third of cases were 10 items respected. Of note, when investigators analyzed the factors predicting a good adherence to measurement guidelines, physicians were significantly less prone to follow the guidelines than nurses. The observations made in this study raise a number of interesting questions. The first concerns the education process both for nurses and medical students. In today's training, much information is given on the clinical importance of detecting and treating arterial hypertension but the time dedicated to learning how to measure blood pressure adequately remains limited and should obviously be improved perhaps using a specific educational program and training sessions as suggested by the authors. In today's training, physicians working in hospital almost never measure blood pressure themselves unless they are following patients in an ambulatory setting. It is also very likely that most nurses do not really know why they are measuring blood pressure every day in these patients and what are the potential consequences of their measurements. Thus blood pressure is measured rapidly as ‘a task that has to be done’ but with no real meaning in it. As discussed in the article, inaccurate measurements of blood pressure can potentially lead to misdiagnosis and inappropriate drug prescriptions [6]. These data would therefore reinforce the idea that the hospital wards are in general not the adequate setting to diagnose and manage hypertension [7]. The real important question is: is it really worth measuring blood pressure so often in hospitalized patients and do these measurements have any value in predicting clinical events? This question was actually asked in a recent prospective study involving more than 600 patients recently admitted to the hospital for a variety of medical conditions [8]. Routine hospital blood pressure values were analyzed with respect to the occurrence of adverse clinical events, the most frequent one being bleeding and falls. Interestingly, the day-to-day variations of blood pressure were comparable in patients, who did not develop any complications and in those developing an adverse clinical event during their stay. Blood pressure measured every day by the nurses had no predictive value for any adverse event including severe bleedings that needed admission in an ICU. The authors of this study therefore concluded that routine blood pressure measurements in hospitalized patients are of little value and should probably be reduced or perhaps even abandoned in the advent of more useful interventions. Reconsidering the value of routine blood pressure measurements in hospitalized patients might enable more time for nurses to perform other activities, which may improve the patients’ outcome and satisfaction. ACKNOWLEDGEMENTS Conflicts of interest There are no conflicts of interest.