YADKIN COUNTY HEALTH DEPARTMENT, Fall 2022
The Site Visit Team identified a best practice to assure the implementation of the new clinical practice guideline by establishing a contract to provide ambulatory blood pressure monitoring equipment to child health patients. This example exemplifies assuring standard of care is met for the underinsured, uninsured and underserved children 13 and over in Yadkin County.
In January 2018, Dr. Gerri Mattson, Pediatric Medical Consultant, with the NC Children and Youth Branch, presented a webinar on the 2017 AAP Guidelines for Childhood Hypertension. The webinar detailed current evidence-based guidelines for the screening and management of blood pressure in children and adolescents. It also discussed the changes that would impact the care delivered to pediatric clients.
Instead of guidelines that come from the National Heart, Lung and Blood Institute, new clinical guidelines are based on a thorough literature review. A subcommittee was formed to develop an updated clinical practice guideline. New changes included rigorous based methodology, new definitions in line with the American Heart Association and the American College of Cardiology guidelines, new normative tables, and a simplified screening table. Now there is emphasis on 24-hour ambulatory blood pressure monitoring to confirm the diagnosis of hypertension.
Prior to this presentation and a review of the in-depth article Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents by the American Academy of Pediatrics, Yadkin County Health Department only checked the blood pressure by auscultation in the arm three times and on multiple visits. If elevated at 95% or greater, they referred to pediatric cardiology. About a year ago, they requested referral be made to pediatric nephrology. The majority of referrals were confirmed as stage I hypertension and either recommended diet changes and/or medication.
After listening to the webinar and reviewing the literature, the agency approved ambulatory blood pressure monitoring when a child returns for a third visit with elevated blood pressure or stage I hypertension. LabCorp provides the device via mail, the agency applies the device to monitor, and the child returns 24 hours later. The device is then mailed back to LabCorp for an interpretation. The blood pressure is then auscultated in the right and left arms and one leg per recommendations. This was implemented in February 2018 and reduces the risk of referring “white coat hypertension” as well as evaluate Circadian BP patterns. It also sets parameters for easier diagnosis of hypertension in children ages 13 and older, reduces the risk of inaccuracies, and is cost effective in evaluating hypertension.