From 20% to 80% Adherence: A Pre-Post Intervention Audit of NICE Guideline Implementation for Hypertensive Emergencies in Pakistan

Abstract Background Hypertensive emergencies require prompt, guideline-based management to prevent life-threatening complications. Despite established protocols like those from the UK’s National Institute for Health and Care Excellence (NICE), adherence remains suboptimal in low-resource settings. This audit evaluated the impact of targeted interventions on compliance with NICE guidelines in a Pakistani emergency department. Methods A pre-post intervention study was conducted at District Headquarters Hospital, Nankana Sahib. Fifty patients with hypertensive emergencies (SBP >180 mmHg and/or DBP >120 mmHg) were audited pre-intervention (December 2023). Interventions included staff training, standardized treatment protocols, and real-time monitoring. A re-audit of 50 patients post-intervention (September 2024) (audit standard: 100% adherence) assessed compliance. Chi-square tests compared pre/post-adherence rates; p < 0.05 was significant. Results Pre-intervention, only 20% (10/50) of cases adhered to NICE guidelines. Post-intervention, adherence rose to 80% (40/50; p < 0.001). Median time to blood pressure control decreased from 5.2 hours (IQR: 3.8–6.5) to 2.1 hours (IQR: 1.5–3.0; p = 0.003). No strokes or myocardial infarctions occurred post-intervention. Conclusions Simple, low-cost interventions (training, protocols, and feedback) significantly improved guideline adherence and reduced time to BP control in a resource-limited setting. Sustained efforts are needed to bridge the remaining 20% gap. These findings support scalable strategies for LMICs to enhance hypertensive emergency care.