An audit and suggested guidelines for in-patient blood pressure measurement

Objective: No universally accepted guideline exists for measurement of blood pressure for patients confined to bed. The aim was to establish areas of technique that might be open to standardization to improve measurement reliability similar to those used for office BP measurements. Methods: In-patient blood pressure measurement (IPBPM) was closely observed in 100 patients in a variety of medical wards during routine vital signs observation rounds, comparing the methods observed with current office BPM guidelines. Results: IPBPM, always taken initially with automated machines, was measured once only in 96% of patients. Around 7% patients were lying flat, 32% semi-reclined, 24% had their back unsupported, 15% crossed legs, 9% arms unsupported, 65% arm below heart level, 4% above, 36% incorrect cuff size for arm circumference, 43% bladder not centred over brachial artery and 14% had arrhythmia not documented by ward staff during the measurement. Staff and patients were conversing during 41% measurements. Conclusion: There is a lack of standardization of automated IPBPM technique including a failure to adhere to principles of measurement already established for office BP in a majority (97%) of patients. This may lead to potentially erroneous BP readings, which are an unreliable basis for clinical interpretation and decision making. There is a need for universal hospital-specific guidelines for IPBPM and programmes to train and monitor staff for adherence to these. Particular attention should be given to those factors well known to affect blood pressure measurement, including correct cuff size and placement, arm position and absence of talking during measurement as well as only using validated machines. Additional recommendations might include the routine use of manual BP readings where appropriate (such as with very low or irregular heart rates), BP measured in both arms on admission and the arm with the highest BP used thereafter and recording the side of IPBPM and patient position. We recommend that a task force is commissioned to develop universal guidelines for this important part of clinical assessment.