Nurse-Driven Training Courses: Impact on Implementation of Ambulatory Blood Pressure Monitoring

Abstract

Background:Ambulatory blood pressure monitoring (ABPM) predicts cardiovascular risk and identifies white-coat and masked hypertension, efficacy of treatment and the circadian cycle of hypertensive patients.Objective:To analyze the effectiveness of ABPM implementation thoughtout a nurse-driven training program.Materials and Methodology:Twenty eight professionals were involved in the study carried out in the primary care center of the metropolitan area of Barcelona that serves 34,289 inhabitants. The ABPM implementation program was driven by two nurses that held four education sessions. After a 2-year follow-up period, we assessed the outcome of attendance at the educational sessions. First, we evaluated whether the program increased the number of orders of ABPM. Second, we used a survey to evaluate to what extent the input of our educational sessions was understood by attendants. Third, we analyzed the effect ABPM results had on the treatment of patients with a bad control of their hypertension.Results:After the training sessions we found a 6-fold increase in the number of patients undergoing ABPM. We analyzed 204 hypertensive individuals: 41% dippers, 34% were non-dippers, 20% were risers and 5% were extremely dippers. According to our survey, 100% of attendants had a good practice regarding ABPM management. However only 27% of riser patients were studied with a second ABPM.Conclusions:Specific training processes are needed for implementation of ABPM and an even more concentrated effort should be focused on training in the correct interpretation of ABPM results.

Assessment of primary healthcare professionals’ management of hypertensive patients with riser pattern

“…Within a continuous education program in accordance with institutional guidelines from Institut Català de la Salut (ICS) four mandatory training sessions on ABPM were conducted by two mentor nurses as we have recently described. 5 In the first two sessions, methods to evaluate cardiovascular risk and the importance of good control over hypertension variables were stressed. The last two sessions were specifically focused on explaining the advantages of ABPM, such as the easy identification of white coat hypertension and obtaining information on the pattern of blood pressure at rest (identification of a dipper, non-dipper, riser or extreme dipper pattern) and the clinical consequences of these specific patterns.…”

“…Twenty-four hour ABPM was performed non-invasively on the non-dominant arm, using a Spacelab’s Model 90207 device and spacing the readings at 20-minute or 30-minute intervals during predicted periods of activity or rest, respectively, as we have previously described. 5 This device was validated and calibrated before the study by Spacelab Medica, S.A., Madrid, Spain.…”

“…The estimation of cardiovascular risk was stratified in four categories: low, middle, high and very high according to the MAPAPRES protocol, taking into account clinical and biological variables. 5,17 Average activity and resting-time ABPM measurements were calculated as described following the protocol and guidelines of MAPAPRES. 4 Dippers are defined as patients who show a physiological 10–20% reduction between the average day and night BP.…”

“…The importance of documenting the pattern of a hypertensive patient is based on the findings that abnormal patterns are more frequent among patients suffering diabetes, obesity or metabolic syndrome, clinical situations associated with a higher cardiovascular risk. 5,7–11…”

“…Two mentor nurses implemented ABPM four year ago in our primary care centre that serves 34,289 inhabitants and is located in the metropolitan area of Barcelona (Spain). 5 Since then, the blood pressure pattern of 450 individuals has been analysed by ABPM. A significant group of hypertensive patients with a riser pattern were detected.…”