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BACKGROUND Optimal triage of patients with hypertensive urgency (HU) in the emergency department (ED) is not well established. 2017 ACC/AHA hypertension (HTN) guidelines recommend treatment initiation and follow-up within 1 week. Objectives of our pilot study were to evaluate feasibility and impact of directly connecting ED patients with HU to outpatient HTN management on blood pressure (BP) control and ED utilization. METHODS ED patients with HU and no primary care physician were scheduled by a referral coordinator for an initial appointment in a HTN clinic embedded within a primary care practice. BP control and ED utilization over the subsequent 90 days were tracked and compared with BP at time of the referral ED visit, and ED utilization in the 90 days preceding referral. RESULTS Data are reported for the first 40 referred patients. Average time to first visit was 7.8 days. Mean age was 51 years (range 28–76), 75% were African-American, and mean pooled 10-year atherosclerotic cardiovascular disease (ASCVD) risk was 20.8%. Mean BP declined from 198/116 mm Hg at ED visit to 167/98 mm Hg at HTN clinic visit 1 to 136/83 by 6 weeks and was sustained at 90 days. Total ED visits for the group decreased from 61 in the 90 days prior to referral, to 18 in the 90 days after the first HTN clinic visit. CONCLUSIONS In this pilot study, coordinated referral between the ED and primary care provides safe, timely care for this high ASCVD risk population and leads to sustained reductions in BP and ED utilization.

Introduction: The incidence of HTN related ED visits is high and increasing. The optimal management of hypertensive urgency in the ED is not well established but the 2017 ACC/AHA HTN guidelines recommend treatment initiation and outpatient follow up within 1 week. There is a low incidence of poor short-term outcomes associated with hypertensive urgency and high cost but low yield for admitting such patients to the hospital. Our health system lacked an effective referral process for these patients, resulting in poor follow up, unnecessary hospital admission, and recurrent ED utilization. The objectives of our pilot study were to 1) create a process for referring and connecting these patients with outpatient HTN management in a primary care setting and 2) measure the impact of this pipeline referral process on BP control and ED utilization. Methods: Patients presenting to the Yale New Haven Hospital ED with hypertensive urgency (SBP ≥180 mm Hg and/or DBP ≥110 mm Hg without end organ damage) who were current patients of the resident physician primary care center or who do not have a PCP were included. Patients meeting inclusion criteria were contacted by a referral coordinator who scheduled their initial appointment to occur within 10 days. Patients were seen by a resident physician supervised by an attending with expertise in HTN. The resident physician leading the visit became their PCP. Results: Data are reported for the first 24 referred patients seen in the clinic. Average time to first clinic visit was 7.5 days. Mean age was 54 years (range 32-71), 85% (20/24) were African-American and mean pooled 10 year ASCVD risk was 19%. Mean BP was reduced from 193/111 mmHg at time of ED visit to 131/77 by six weeks after first visit and was sustained at 90 days. Total ED visits by these 24 patients decreased from 30 in the 90 days prior to referral, to 11 in the 90 days after the first clinic visit. Discussion: Our results show that ED patients with hypertensive urgency are a high ASCVD risk population. A coordinated referral collaboration between the ED and primary care can provide safe, timely care for this at-risk population that leads to significant reductions in BP and ED utilization. Reduced ED utilization is most likely due to connecting patients with comprehensive primary care.

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