SPECIAL REPORT
Severe hypertension in the ED: What do to with that confusing number
By William J. Naber, MD, FACEP, Assistant Professor, Department of Emergency Medicine, University of Cincinnati, College of Medicine; Second year, University of Cincinnati College of Law.
Treatment of severe hypertension in today's busy emergency departments can be confusing and a large source of medical liability. Recent guidelines published in March 2008 by the American College of Emergency Physicians (ACEP) and written by the Emergency Medicine Cardiac Research and Education Group (EMCREG)-International Consensus Panel have clarified many areas of treatment of hypertension and hypertensive emergencies with evidenced-based guidelines.1 Following these guidelines, along with those of the American Heart Association in The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) published in 2003,2 can help prudent emergency medicine clinicians formulate a solid foundation to protect them from liability.
However, guidelines are most useful when applied along with proper documentation of the differential diagnoses considered, follow-up on labs ordered, treatments considered and/or given, and the education provided to the patients at discharge.
Treatment of the symptomatic severely hypertensive patient does not seem to be the major problem, it is the asymptomatic and newly diagnosed patients who are the most difficult to handle. The legal literature and published cases seem to follow two themes of misguided treatment: 1) failure to respect that hypertension frequently is a clue to a greater problem; and 2) failure to educate patients about their disease. Severe hypertension often is not an isolated problem but rather a major risk factor to current and future diseases. Severe hypertension can lead to devastating illnesses such as stroke, myocardial infarction, intracranial hemorrhage, and eclampsia; these diseases are just a few involved in the high profile and high dollar cases.
In McCallister v. Franklin County Memorial Hospital, David McCallister presented to the ED complaining of "a burning sensation in the epigastric region."3 The emergency physician in this case noted that McCallister "had high stress levels, was a heavy smoker, and that he was not, at that time, taking any medications to reduce his blood pressure."4 A physical exam and ECG were done, no laboratory studies were ordered. The ECG was considered "non-diagnostic."5 The emergency physician felt McCallister was "experiencing reflux ... [McCallister] was diagnosed with hypertension and abdominal pain ... prescribed Prilosec" and was discharged.6 He died less than three months later of a myocardial infarction, while still taking his medication for "reflux." McCallister's treating physician was an employee of the hospital, so the family filed suit alleging "that the Hospital was negligent in its examination, treatment, and diagnosis of David McCallister, contributing to his death."7 The trial proceeded in front of a judge and was won by the physician and hospital thanks to what the judge described as "persuasive" expert opinion for the defense.8 In reading this case, one could easily imagine the opposite outcome and a large settlement if it had been tried by a jury or less persuasive expert testimony was given. Respect for the effects of severe hypertension may have avoided this lawsuit for the hospital and physician.
Along a similar theme, in Ricciardi v. St. Mary's Hospital, Rudulph Ricciardi presented to the ED, where he was "described as confused, had a history of hypertension and presented with 'markedly uncontrolled blood pressure' and complaints of 'paresthesias of the left hand and fingers.'"9 Ricciardi was discharged "[a]fter several apparently inconclusive tests ... with advice to follow-up with his physician within 48 hours. Two days later, Ricciardi suffered a 'massive stroke.'"10 Unfortunately, the available legal record does not mention which specific tests were ordered, any intervention outside of advised follow-up by the treating physician, and if follow-up was ever achieved. The bottom line is that Ricciardi suffered from a bad outcome, one that a judge or jury may deem foreseeable in light of his uncontrolled blood pressure in the ED and neurological symptoms. The large stroke led Mr. and Mrs. Ricciardi to file suit against the hospital and treating physicians for allegedly breaching the recognized standard of care, resulting in personal injury and damages. Connecticut state law "requires that an attorney filing a civil action for damages alleged to be the result of the negligence of a health care provider, must obtain a signed written opinion from a 'similar health care provider' that there appears to be evidence of medical negligence including a detailed basis for the formation of the opinion."11 The hospital filed a motion for dismissal based on the fact that the physician who filed the opinion with the case was not board certified in emergency medicine, and therefore not similar to one of the defendants. The Superior Court of Connecticut disagreed with the defense and denied the motion for dismissal. The defendant physicians now find themselves still in court and spending more money and emotional energy on this case. The final judgment in this case was not available; however, this case suggests that uncontrolled hypertension may have been a factor.
These cases address liability from failure to diagnose two very different medical problems. Both cases, however, mention severe hypertension as part of the patients' presentation and presumably as a clue to the death and disability that followed. As EDs become more crowded, sometimes details such as uncontrolled hypertension may get overlooked or incompletely addressed.
Judging by the lack of legal cases found, recognition and treatment of obvious hypertensive emergencies does not seem to be a widespread liability issue for emergency medicine. Significant amounts of training and education are given to residents about classic board type subjects such as hypertensive encephalopathy, eclampsia, stroke, and heart failure. The dilemma arises when patients come to the ED for something completely unrelated to blood pressure, but are found to be hypertensive. An example would be the patient who comes to the ED because of an ankle sprain, but who is discovered to have undiagnosed hypertension with a blood pressure of 200/100. What does the prudent emergency provider do with that number?
In researching this issue, the law does not seem to give an answer to that specific question, but general legal principles, along with current national recommendations for hypertension treatment, should. Remember, to prove medical malpractice, a patient must show that the medical provider failed to conform to the applicable standard of care during treatment, and that this failure was the proximate cause of the injury suffered. The American Heart Association in JNC-7 and more recently ACEP both have described and recommended a standard of care for these patients.
The JNC-7 report highlights the importance of addressing these asymptomatic patients in that "[f]or every 20 mm Hg systolic or 10 mm Hg diastolic increase in BP [over 115/75], there is a doubling of mortality from both ischemic heart disease and stroke."2 The JNC-7 recommendations were reviewed by the EMCREG Consensus Panel in light of the best evidence available, and guidelines were issued for the follow-up and treatment of elevated blood pressure in the ED. The urgency for follow-up logically parallels the level of the blood pressure. At lower levels (120-140/80-90), simple follow-up is advised. As a patient's blood pressure rises, the interval for follow-up shortens. At blood pressures of over 180/110, consideration of treatment is advised along with follow-up within one week.12 As the patient's blood pressure goes over 200/120, initiation of treatment is advised with follow-up in less than one week. The JNC-7 report also recommends that the patient's basic metabolic profile be checked prior to beginning therapy, as the test results may change the choice of medication.2 Thanks to $4 prescription programs, many of these first-line medications are now affordable for uninsured patients.
Emergency physicians may avoid legal pitfalls by paying attention to elevated blood pressures in children and adults. Hypertension is a significant risk factor for cardiovascular disease, stroke, and kidney failure. Knowing and following the major published guidelines discussed above can improve patient care and decrease the risk emergency physicians' face in ever busier emergency departments.
References
1. The EMCREG-International Consensus Panel. Management of hypertension and hypertensive emergencies in the emergency department. Ann Emerg Med 2008;51(3 Suppl):S1-S38.
2. Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-1252.
3. McCallister v. Franklin County Memorial Hospital, 910 So.2d 1205 at 4 (Miss. App. 2005).
4. McCallister at 4.
5. McCallister at 4.
6. McCallister at 4.
7. McCallister at 1.
8. McCallister at 17.
9. Ricciardi v. St. Mary's Hospital, 2007 Conn. Super. Lexus 1099 at *3.
10. Ricciardi at *4.
11. Ricciardi at **2,3.
12. Slovis CM, Reddi AS. Increased blood pressure without evidence of acute end organ damage. Ann Emerg Med 2008;51(3 Suppl):S7-S9.
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