IMPROVING EFFICIENT CARE DELIVERY IN PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT WITH SEVERE HYPERTENSION: A DELPHI STUDY

Objective: Approximately 1-2% of all emergency department (ED) visits involve suspected hypertensive emergencies. For these patients, the most efficient treatment is yet to be established as evidence from clinical trials is missing and adoption of the current guidelines in daily practice is therefore limited. To improve the current diagnostic- and treatment algorithm and increase guideline adoption, a Delphi procedure amongst hypertension experts was conducted.Design and method: A Delphi method of consensus development was used consisting of three survey rounds. In the first round, experts were asked to rate agreement/disagreement across 43 statements. Of these, 24 statements addressed clinical workflow, blood pressure monitoring and diagnostic work-up. The remaining 19 statements assessed acceptable risks for major adverse cardiovascular events and 30-day readmissions if patients with severe hypertension were discharged directly from the ED based on various clinical scenarios. The clinical statements informed the development of a more efficient diagnostic- and treatment algorithm, while the risk statements will guide the design of a future trial to evaluate the algorithm. Experts were asked to contribute additional statements in round 1 and these were incorporated in round 2 (n=4). In rounds 2 and 3 experts re-evaluated their responses in light of panel consensus. Consensus was defined as =/>70% agreement on a given statement. Results: Eighteen hypertension experts consisting of internal- and emergency medicine specialists from academic and teaching hospitals were invited to participate. Fifteen experts gave consent and out of these fourteen (93% response rate) completed round 1 and twelve completed rounds 2 and 3 (80% response rate). Consensus was achieved for 38 statements (93%). The panel identified five areas where efficiency could be improved (table 1). Acceptable adverse cardiovascular events risks and readmission risks were 1% and 5% respectively across all clinical scenarios. Conclusions: The expert panel agreed that efficient care delivery for patients presenting to the emergency department could be improved. The panels’ suggestions can be translated to a more efficient diagnostic- and treatment algorithm which, prior to implementation, requires a prospective evaluation.