Attitude and practice regarding effective blood pressure measurement among health professionals at a tertiary care hospital in Hyderabad - Pakistan

Background: Blood pressure (BP) measurement is one of the basic indicator used for the diagnosis, treatment and research investigations of Hypertension. The accuracy of the measurements have the potential to influence the decision making and therefore is a prerequisite, regardless of which technique is used. Still, too often the accuracy of measurement is taken for granted in general practice. This study aims to gauge the attitude and practice of health professionals regarding effective BP measurement at a tertiary care hospital. Methodology: This cross-sectional study comprised of 50 healthcare professionals, chosen via purposive sampling from Liaquat University Hospital, a tertiary care hospital at Jamshoro, Hyderabad during November, 2015 to January, 2016. A self-administered structured qualitative and quantitative questionnaire was used to evaluate the attitude and practice of effective BP measurement. The data was analyzed through SPSS version 19 and Microsoft Excel. Results: According to the study results, 88% of the participants had clinical experience of up to 5 years. Around 56% of the respondents rated their BP measurement skills as very good, 38% as good while 6% as acceptable. It was found that 46% of the respondents use to measure BP only once whereas 54% do it twice to get a mean value. For the location of measuring the BP, 60% responded to use only one arm while, 40% reported to measure it from both arms. Furthermore, many of the respondents reported for never attending any Continuous Medical Education (CME) regarding BP measurement along with the 48%, who declared that they had never updated their knowledge regarding BP measurement guidelines. Conclusion: It is evident from the survey that selected set of healthcare professionals had lesser focus toward accurate methods of BP measurement as well as low interest in updating their knowledge regarding the standard protocols. It is concluded that up gradation of knowledge and awareness reading standard and current practices must be taught regularly and must be mandatory to follow for all healthcare providers.


Introduction
The guidelines for BP measurement were first published by American Heart Association published in 1988 but from then till now studies showed that these are either less known or overlooked by health care workers 1 . BP is most common of vitals used routinely in healthcare setting with Auscultation method being the most common one. The most widely used method for BP measurement is the Auscultation method giving systolic and diastolic values. Normal systolic and diastolic values are <120 mmHg and <80 mmHg respectively and anything more than that falls into the categories of Prehypertension (120-139 mmHg/80-89 mmHg), Stage 1 Hypertension (140-159 mmHg/90-99 mmHg) and Stage 2 Hypertension (>=160 mmHg/>=100 mmHg) as per the American Heart Association 2 . High BP increases the risk of developing narrowed arteries that lead to heart problems and strokes. In the Asian-Pacific region, up to 66% of some subtypes of Cardiovascular Disease (CVD) can be attributed to hypertension, underscoring the immense impact that BP lowering strategies could have in this populous region 3 . For treating and controlling cardiac morbidity, accurate diagnosis is a requirement. Therefore it is imperative to have an early and accurate assessment of BP to diagnose and treat such diseases.
Accurate measurement of BP is essential to categorize individuals on the basis of their pressure type, to ascertain BP-related risk, and to guide management 2 . The auscultatory technique with a trained observer and mercury sphygmomanometer continues to be the method of choice for measurement, using the first and fifth phases of the Korotkoff sounds, including in pregnant women 2 . Worldwide prevalence estimates for hypertension may be as much as 1 billion individuals and approximately 7.1 million deaths may be credited to hypertension every year 4 . It has been identified as the leading global risk factor for death or disability 5 . Studies have shown that worldwide, high BP affects > 40% of the adult population older than the age of 25 years 6 . The estimated number of adults with raised blood pressure increased from 594 million in 1975 to 1·13 billion in 2015, comprising 597 million men and 529 million women 7 .
Hypertension is one of the prominent causes of cerebrovascular and cardiac morbidity. It is also a major risk factor for cardiovascular disease, chronic kidney disease, and death, remaining largely silent until the development of complications 8 . Hypertension not only increases the risk of heart attack and stroke but also is an originator for congestive heart failure, chronic occlusive peripheral vascular disease, aortic aneurysm, and renal failure 9 . Terminal digit preference, which is a common source of error during manual BP examinations, is the rounding off the numbers to nearest zero. Usually, the result is an inappropriate increase in the diagnosis of hypertension because SBP in the upper 130s are rounded up to 140 mm Hg 9 . A study demonstrated that traditionally trained nurses had terminal digit preference while measuring the BP 10 . This resulted in underestimation by >5%mm Hg among 57.5% of the patients causing misjudgements for hypertensive patients 10 . Healthcare professional's attitude and practice towards BP measurement may lead to overestimation or underestimation of arterial BP which may result in patients being labelled with hypertension even when they aren't hypertensive and vice versa 11 . Nurses often find that it is faster and easier to take a forearm BP than to search for a larger cuff 12 . Studies have shown that forearm BP generally runs 3.6/2.1 mm Hg higher than upper arm BP 13 .
This study aims to analyse the competency of health care professionals in the measurement of BP in relation to the standard guidelines of BP measurement. It also evaluates their attitude

Methodology
This cross-sectional study comprised of 50 healthcare professionals chosen via purposive sampling from November 30th, 2015 to January 28th, 2016 at a tertiary care hospital i.e. Liaquat University Hospital, Jamshoro. For inclusion into the study, the subjects were required to have a minimum experience of 6 months in BP measurement with sphygmomanometer only. Subjects using a digital device for measurement and students were excluded from the study sample.
A self-administered structured qualitative and quantitative questionnaire was used to evaluate the knowledge of healthcare professionals regarding BP measurement. The study continued for 2 months. Data was collected from the subjects through the questionnaire on period of experience, self-evaluation for their skills in the measurement of BP, the last time they updated their knowledge on recent guidelines and how well the standard guidelines were followed. The data was analyzed through SPSS version 19 and Microsoft Excel. The results were tabulated as frequency and percentages.

Results
Out of the 50 healthcare providers 19 (38%) were males and 31 (62) were females. Majority of the subjects i.e. 88% had work experience of up to 5 years in the medical field. According to the results 56% study subjects rated their BP skills as very good, 38% as good and 6% of the sample rated their skills as acceptable. It was observed that 60% of the healthcare providers preferred measuring BP from one arm while only 40% measured on both arms. As per table 1, 48% of the subjects declared that they had never updated their knowledge regarding BP measurement guidelines. Moreover, 74% of the respondents had never attended any CME regarding BP measurement. of knowledge concerning the subject. Our results indicated that the majority of the study subjects rated their BP skills as very good (Table 1), yet failed to follow measurement guidelines. BP knowledge regarding BP is not a common practice in the healthcare world, as professionals tend to stick to similar measurement routine and trust their ability to measure BP quite a lot.
A daily routine skill is neglected by healthcare systems and there is no emphasis on training and educating the staff for basic skills such as BP measurement which is why 48% of the participants confessed to never updating their knowledge and 78% of the sample never attended any CME concerning BP measurement ( Table 2). Health care systems should operate in a way that supports a better and safer environment for patients but unfortunately alike the professionals the system doesn't focus on such learning/training programs. This lack of knowledge could lead to incorrect labelling of hypertensive and nonhypertensive patients according to modern guidelines and classifications 14 .
Mis-cuffing is a very well researched topic but still remains a common medical mistake in the healthcare community. A very long study from different regions of the world published in The New England Journal of Medicine indicates that an increase of 10 mmHg in SBP increases the relative risk of death from coronary heart disease by 28% also 5 mmHg increase in DBP had a similar effect 14 . This demonstrates the significance of slight increases in BP and the necessity of accurate BP measurement for diagnosis, treatment and management 14 . Using a standard BP arm cuff on an obese patient, leading to a tight cuff falsely raises systolic blood pressure by approximately 10 mm Hg 12 .
Our survey explains that healthcare professionals have insufficient understanding of mis-cuffing as only 30% of the respondents (Figure 1) The overall study showed that the majority of the subjects believed that they had sufficient BP measuring skills for their profession. Failure to update knowledge regarding BP through CMEs or any other methods made them self-satisfied and competent enough to challenge and work without insecurities and held them unaware of the new and updated facts about BP measurement. There are also technical errors in their measurement practices and many of the subjects are not aware of it and relevant authorities should pay attention to organizing awareness through initiating session and training programs.
International Journal of Endorsing Health Science Research Int. j. endorsing health sci. res.

Conclusion
The study results concluded that the healthcare professionals of selected tertiary care hospital were not fully equipped with the updated knowledge and put less efforts in using standard procedures. It is recommended that focused training of health professional with contemporary and standard protocols will be beneficial to improve quality of healthcare outcomes.

Conflicts of Interest
None.