Early and Accurate Diagnosis of Pediatric Hypertension at Arkansas Children’s

Significantly Increasing Patients Served

Early and accurate diagnosis of hypertension is a crucial step toward reducing preventable deaths caused by the condition. Identification and prevention of hypertension before adulthood is vital, so Arkansas Children's Hospital Nephrology/Hypertension Clinic prioritized expanding the 24-hour ambulatory blood pressure monitoring (ABPM) program.

The number of patients benefitting from the program at Arkansas Children's Hospital has more than quadrupled since 2017. Approximately 600 patients are evaluated yearly using ABPM, including some patients from neighboring states. Mohammad Ilyas, M.D., a pediatric nephrologist at Arkansas Children's Hospital and associate professor of Pediatrics in the Division of Nephrology at the University of Arkansas for Medical Sciences, has been a part of the ABPM program since its inception at Arkansas Children’s Hospital nearly 20 years ago.

"ABPM accurately measures blood pressure and evaluates for 'white-coat' and masked hypertension and helps identify the actual hypertensive patient, which can be treated because childhood hypertension has links with adult hypertension," Ilyas said. 

Patient safety is a core value at Arkansas Children's. In this context, patient safety means ensuring a child isn't unnecessarily prescribed medication due to a false diagnosis of hypertension or some other condition. Medicines for treating high blood pressure can have long-lasting adverse side effects. Additionally, Arkansas Children's recognizes that the blood and urine tests, along with the ultrasounds or echocardiograms required for patients diagnosed with hypertension, can be costly. Prioritizing accurate diagnoses reduces unnecessary expense and stress for the patient's caregivers.

Collaborating with Colleagues

The number of patients served began increasing when the Nephrology department at Arkansas Children’s Hospital adopted the recommendations of "Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents," published in 2017 by the American Academy of Pediatrics, which advises confirming suspected hypertension in children with ABPM. This includes patients with chronic kidney disease, renal transplantation, obstructive sleep apnea, coarctation of the aorta and who are on dialysis.  The Nephrology/Hypertension Clinic uses Spacelabs Ontrak ambulatory blood pressure monitors, validated for use with pediatric patients by the Association for the Advancement of Medical Instrumentation (AAMI) and the British Hypertension Society.

Data collected from ABPM devices includes the 24-hour average blood pressure, the average daytime blood pressure, the average nighttime blood pressure and the calculated percentage drop in blood pressure at night.

ABPM is more predictive of future blood pressure and can help detect secondary hypertension. "The results collected via ABPM are more reproducible and correlate better with target organ damage," Ilyas said. ABPM can also help track the effectiveness of treatments after a patient is diagnosed with hypertension and started on treatment.

ABPM has value as both a diagnostic tool and a means to evaluate the effectiveness of treatment plans. In the case of pharmacological treatments, intermittent use of ABPM can be used for the titration of blood pressure medications.

Dedicated Coordinator Improves Patient Experience

To accommodate the increase in patients, the Nephrology department at Arkansas Children's Hospital hired a dedicated coordinator who organizes all aspects of the ABPM program and provides a point-of-contact for patients and referring physicians. Having a dedicated coordinator and increased availability of ABPM monitors has facilitated a dramatic decrease in wait times despite increasing the number of patients served to an average of 50 each month. The waiting period for patients, once as long as two months, has been reduced to one week.

Educating patients and their caregivers is another strategy for ensuring the accuracy of measurements taken via ABPM. The Nephrology department uses a three-pronged approach to accuracy:

• in-person demonstrations during a clinic visit
• an educational brochure with written details on the correct placement and use of the monitor
• an educational video aimed at a pediatric audience providing troubleshooting tips in addition to standard application instructions

Education on accurate blood pressure measurement extends beyond patient families. A collaborative effort between the Nephrology department and the primary care clinic at Arkansas Children's Hospital also provides hospital-wide quality improvement instruction on how to use standard blood pressure cuffs more effectively. If a patient's blood pressure is high based on two standard readings and the patient is suspected of having hypertension, a referral to the ABPM program can be ordered.

Arkansas Children's Hospital is committed to going above and beyond best practices to achieve accurate blood pressure readings, which lead to accurate diagnoses for kids – championing children by making them better today and healthier tomorrow.