High blood pressure goes unrecognized in ED

Make patients aware of need for recheck

A patient comes in with a superficial laceration that is expertly assessed by the ED nurse and repaired by the ED physician — but the patient's hypertension is missed.

"We do a good job, but we miss the opportunity to have a much greater impact on their health by telling them their blood pressure is elevated," says Francis Counselman, MD, chairman of the Department of Emergency Medicine at Eastern Virginia Medical School in Norfolk. "In the long run, that might be much more important than the reason they are in the ED."

Only a small percentage of ED patients with asymptomatic elevated blood pressure are recognized, treated, or referred, according to a new study.1 Researchers looked at 1,574 patients whose documented blood pressure was 140/90 mm Hg or higher. They found that only 112 received attention for their elevated blood pressure, such as diagnosis, treatment, a medication prescription, or a referral.

If a patient's blood pressure still is elevated on recheck, as they are getting ready for discharge, remind the physician to refer the patient for a blood pressure check, says Counselman, one of the study's authors. Also, inform the patient that their blood pressure is elevated, he says.

Patient should follow up

The most important actions are recognition and having the patient follow up, Counselman says.

"We don't need to necessarily treat the vast majority of these; we just need to let the patient know their blood pressure is elevated," he says. "It may be because they are nervous or in pain or scared, but it may be because they have hypertension."

Many adults have hypertension that goes unrecognized, and catching it early can prevent secondary damage to the kidneys, heart, and brain, says Counselman. "If nurses can be on the lookout as well as physicians, then we've got twice the opportunity to recognize it and get the patient headed in the right direction," he says.

At Aurora Medical Center in Oshkosh, WI, ED nurses check blood pressure on every patient five years and older, no matter what the complaint or symptoms, says Jane Hottinger, RN, MSN, clinical educator for the ED. If blood pressure is elevated, it is circled on the paper chart and repeated in 15 minutes, since the "white coat syndrome" is a possible factor, she says.

The ED's electronic charting program, FirstNet (Cerner Corp.; Kansas City, MO), is preprogrammed with high or low blood pressure readings, and alarms with flashing lights alert staff to abnormal readings. "If it exceeds our present limits, the physicians have to address it when they access the electronic chart," says Hottinger. "This way, we rarely miss the opportunity to address unidentified hypertension."


  1. Tilman K, DeLashaw M, Lowe S, et al. Recognizing asymptomatic elevated blood pressure in ED patients: How good (bad) are we? Am J Emerg Med 2007; 25:313-317.


For more information on blood pressure assessment in the ED, contact:

  • Francis Counselman, MD, Eastern Virginia Medical School, Raleigh Building, Room 304, 600 Gresham Drive, Norfolk, VA 23507. Phone: (757) 388-3397. E-mail: counsefl@evms.edu.
  • Jane Hottinger, RN, MSN, Clinical Educator, Emergency Department, Aurora Medical Center, 855 N. Westhaven Drive, Oshkosh, WI 54904. Phone: (920) 456-7420. Fax: (920) 456-7421. E-mail: dhottinger@new.rr.com.