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Contact Details
Lisa Allman
Senior Pharmacist Community Pharmacy Scheme Development
NHS Halton Clinical Commissioning Group
First floor, Runcorn Town Hall, Heath Road, Runcorn, WA7 5TD
Mobile: 07887 510703
E-mail: [email protected]
Direct dial: 01928 593452 Fax: 01928 593790 Website: www.haltonccg.nhs.uk
Gareth Rustage
Senior Technician Community Pharmacy Scheme Development
NHS Halton Clinical Commissioning Group
First floor, Runcorn Town Hall, Heath Road, Runcorn, WA7 5TD
Mobile: 07795 540763
E-mail: [email protected]
Direct dial: 01928 593452
Fax: 01928 593790 Website: www.haltonccg.nhs.uk
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Contents
Page No.
The Service 4
High Blood Pressure- Hypertension 6
Ambulatory blood pressure monitoring 7
Atrial Fibrillation 8
Microlife Blood Pressure Meters 9
Preparing to deliver the service 10
Service Promotion 13
Engagement and Screening 14
Introduction and client information 16
Measuring blood pressure 17
Explain the blood pressure results and next steps 19
Re-checking clinic BP 23
Performing ABPM 24
Lifestyle discussion on maintaining a healthy blood pressure 29
Closing 31
Records 32
PharmOutcomes® 32
Payment 34
Appendix one- Resources to support delivery of the service 35
Appendix Two – Consent Form 37
Appendix Three – Levels of Physical Activity using the General Practice Physical Activity Questionnaire
38
Appendix Four – Referral to Health Improvement services 39
Appendix Five – Loan of ambulatory blood pressure monitor. 40
References 41
.
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Hypertension is persistently raised arterial blood pressure, and is one of several risk
factors for diseases such as heart failure, myocardial infarction, stroke, and chronic
kidney disease. High blood pressure affects more than one in four adults in England, and
is the second biggest risk factor for premature death and disabilityi. Diseases caused by
high blood pressure cost the NHS over £2billion every year.
Atrial fibrillation is the most common cardiac arrhythmia, affecting between 1‐ 2% of the
general UK population and is related to 20% of all strokes.
Many of the cardiovascular diseases screened for are asymptomatic which suggests that
current numbers of people with atrial fibrillation and hypertension are most likely to be
underestimated.
The burden of high blood pressure is greatest among individuals from low-income
households and those living in deprived areas. People from the most deprived areas are
30% more likely than the least-deprived to have hypertension. In 2015, 44.9% of the
population of NHS Halton CCG lived within the most deprived 30% of all areas in
England.ii
The lifestyle risk factors for hypertension; obesity, lack of exercise and excess alcohol
drinking have been combined and weighted to produce an overall lifestyle hypertension
ranking for each CCG. NHS Halton CCG ranks 207 out of 209 CCGs for the combined
lifestyle risk factors for hypertension.
In November 2014 Public Health England (PHE) published Tackling high blood pressure:
from evidence into actioniii. This document provides evidence-based advice on how local
government, the health system and others can effectively identify, treat and prevent high
blood pressure. Actions identified included
Clinical Commissioning Groups (CCGs) should consider the case for local
investment in Enhanced community pharmacy services to provide better
information and support about blood pressure management; to introduce
opportunistic screening in some areas; and to use the Medicines Use Review
(MUR) service to review the blood pressure of those on anti-antihypertensives and
others at high risk of developing high blood pressure
Healthcare professionals, including pharmacists and their teams, should take the
opportunity of client engagement to test the blood pressure of all adults regularly
and carry out pulse checks as part of blood pressure measurement
Halton CCG is committed to the principle that improving access within our new model for
General Practice includes identifying and supporting the cohort of the population whom
we have termed the ‘Hidden 40%’. i.e. approximately 40% of the population who are not
The Service
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accessing General Practice services in a timely way and therefore, have a health
inequality gap which results in them having a significantly reduced life expectancy. This
means that in Halton, nearly every other person you walk past suffers from a hidden
health burden. Screening for Hypertension and AF in community Pharmacy and
providing signposting to appropriate lifestyle advice supports this principle.
In collaboration with Halton St Helens and Knowsley LPC, Halton CCG has developed a
pilot service to screen Halton residents for hypertension and atrial fibrillation through
community pharmacies.
Appropriate management of clients identified with hypertension or AF will help prevent
heart disease, stroke, diabetes, kidney disease and certain types of dementia.
Prevention of these chronic diseases will reduce the demand on GP appointments, A&E
attendances, and OOH appointments due to deterioration in symptoms.
Clients identified as at risk of developing hypertension will receive advice on reducing
their future risk of cardiovascular disease by addressing their modifiable risk factors for
cardiovascular disease(such as excess weight, dietary salt or alcohol), supporting a
strategy of self- care.
Many pharmacies already offer Blood pressure testing. However this scheme will offer
clients with a clinic blood pressure of 140/90 mmHg or higher, ambulatory blood
pressure monitoring (ABPM) to confirm the diagnosis of hypertension from the pharmacy,
a pathway that would have traditionally required GP practice input requiring multiple
appointments at an earlier stage.
The pilot service will run from May to September 2016. The pilot provides the opportunity
to demonstrate that community pharmacists can have an effective role in identifying
people with undiagnosed high blood pressure and atrial fibrillation.
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Why focus on high blood pressure?
High blood pressure rarely makes people feel ill and there are usually no symptoms.
It greatly increases the risk of cardiovascular disease, in particular heart attack,
stroke and heart failure, and unfortunately often goes undetected until an acute
event occurs,iv so early detection is key.
High blood pressure is a systolic blood pressure above 140mmHg, or a
diastolic blood pressure above 90mmHg.v
High blood pressure affects over a quarter of all adults in England.
One in every nine adults – over 5 million people in England – has high blood
pressure without knowing about it.
Prevalence increases with age in both men and women.
In around 90% of cases there is no obvious, identifiable cause.
High blood pressure is the second biggest risk factor for disease leading to early
death in the UK.vi
High blood pressure is estimated to cause over 20% of heart attacksvii and 50%
of strokes.viii
The risk of a cardiovascular event doubles for approximately every
20/10mmHg rise in blood pressure.v
Current guidelines
In 2011 the National Institute for Health and Clinical Excellence (NICE) updated its
clinical guidelines for hypertension, based on the best available research evidence to
promote high-quality care and clinical practice. One of the key recommendations of
the NICE is that blood pressure can be lowered through a range of lifestyle changes –
such as cutting down on salt, and reducing alcohol consumption – and options for
treatment with medicines. The full guideline can be accessed at
https://www.nice.org.uk/guidance/CG127 or a summary of the guidance provided by
NICE Clinical Knowledge Summaries (CKS) can be viewed at
http://cks.nice.org.uk/hypertension-not-diabetic
Case Study
The case study about how Ann is fighting to control her blood pressure
(www.youtube.com/watch?v=UuKnpFrFVR4#t=20) provides a useful reminder of
why monitoring blood pressure is important and the positive impact it can have on
a person’s life. The case study can also be watched in British Sign Language
(https://www.youtube.com/watch?v=YdxSAcnElM8#t=22)
High Blood Pressure
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Many pharmacies already offer Blood pressure testing.
However having a raised blood pressure reading in one test does not
necessarily mean you have high blood pressure (hypertension).
Blood pressure can fluctuate throughout the day.
Feeling anxious or stressed when you have your Blood pressure
measured can also raise your blood pressure.
Some people get worried about seeing their doctor, and having their blood
pressure measured can make it go up. This is known as the ‘white coat
syndrome’ or ‘white coat effect’.
Pharmacies offering this service will offer clients with a clinic blood pressure of
140/90 mmHg or higher, Ambulatory Blood Pressure Monitoring (ABPM) as
recommended in the NICE clinical guidelines for hypertension.
Ambulatory blood pressure monitoring (ABPM) is a non-invasive method of obtaining
blood pressure readings over a 24-hour period, whilst the client is in their own
environment, representing a true reflection of their blood pressure.
ABPM involves fitting a blood pressure cuff, connected to a small device on a belt or
strap worn on the body for 24 hours.
The monitor is set up to automatically measure blood pressure at regular intervals
throughout the day, so that average blood pressure can be calculated. Whilst having
this type of monitoring, clients can carry on with all usual activities apart from having a
bath or shower, or going swimming.
NICE recommends ensuring that at least two measurements per hour are taken
during the person's usual waking hours (for example, between 08:00 and 22:00
hours). The average value of at least 14 measurements taken during the person's
usual waking hours can be used to confirm a diagnosis of hypertension.
Ambulatory Blood Pressure Monitoring (ABPM)
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Fibrillation High Blood Pressure
Why focus on Atrial Fibrilllation?
Atrial fibrillation (AF) is an arrhythmia. It results from irregular, disorganized
electrical activity in the atria, leading to an irregular ventricular rhythm. The
ventricular rate of untreated AF often averages between 160–180 beats per minute
(although this is typically slower in elderly people). This short video explains more:
https://www.youtube.com/watch?v=Ok-PK-UI-4k
The most common causes of AF are ischaemic heart disease, hypertension, valvular
heart disease, and hyperthyroidism.
AF should be suspected in people with an irregular pulse. If AF is present, an ECG will
show no P-waves, a chaotic baseline, and an irregular ventricular rate.
Complications of AF include ix
Stroke and thromboembolism
People with AF have a five-fold greater risk of stroke and thromboembolism
than people without AF. However, this risk is not homogeneous, and is
dependent on the presence of various stroke risk factors.
Stroke severity is usually greater when stroke is associated with AF than with
other causes
Heart failure
Tachycardia-induced cardiomyopathy and critical cardiac ischaemia.
Reduced quality of life
AF can result in reduced exercise tolerance and impaired cognitive function
Management of AF
Management of AF includes:
Identifying and managing any underlying causes.
Treating the arrhythmia: a rate-control treatment (beta-blocker, rate-limiting
calcium channel blocker, or digoxin) is recommended for most people with AF.
Referral for rhythm-control treatment (cardioversion), in addition to rate-control
treatment, may be appropriate if the person has AF with a reversible cause (for
example a chest infection); heart failure thought to be primarily caused, or
worsened, by AF; or new-onset AF.
Assessing stroke risk using the CHA2DS2VASc assessment tool.
Assessing the risks and benefits of anticoagulation and starting treatment if
appropriate.
Arranging follow up to assess compliance with treatment, efficacy of treatment,
and tolerability.
Providing advice and information on AF, its treatment, and where to find support
groups
Atrial Fibrillation
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Current guidelines
In 2014 the National Institute for Health and Clinical Excellence (NICE) updated its
clinical guideline for Atrial Fibrillation Management, based on the best available
research evidence to promote high-quality care and clinical practice. The full guideline
can be accessed at https://www.nice.org.uk/guidance/cg180 or a summary of the
guidance provided by NICE Clinical Knowledge Summaries (CKS) can be viewed at
http://cks.nice.org.uk/atrial-fibrillation
Each pharmacy will be provided with blood pressure monitoring devices from the
Microlife Watch BP range.
Microlife WatchBP Home A
The Watch BP Home A device (Microlife) is an oscillometric blood pressure monitor.
While recording blood pressure, it automatically detects pulse irregularity that may be
caused by symptomatic or asymptomatic atrial fibrillation. The WatchBP Home A
device has an embedded algorithm that calculates the
irregularity index (standard deviation divided by mean) based on interval times
between heartbeats. If the irregularity index exceeds a defined threshold value,
atrial fibrillation is likely to be present and an atrial fibrillation icon is displayed
on the device.
NICE has considered the evidence on the use of this devicex. The available evidence
suggests that the device reliably detects atrial fibrillation and may increase the rate of
detection when used in primary care. This would allow prophylactic treatment to be
given to reduce the incidence of atrial fibrillation-related stroke. WatchBP Home A
should be considered for use in people with suspected hypertension and those being
screened or monitored for hypertension, in primary care
Microlife Watch BP 03 Ambulatory
A Professional 24-hour blood pressure monitor, which includes the same AF detection
technologies as the Home A device allowing ambulatory monitoring of clients identified
with high clinic blood pressures, and the added facility to demonstrate period of AF
detection during the monitoring process.
Extra large cuffs will also be provided for each device.
Full instruction manuals and operating software will be provided for each device.
Microlife Blood Pressure Meters
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Consultation room
The pharmacy must be able to provide a consultation room in which to undertake
blood pressure measurements and advice.
Consultation rooms must meet the following requirements:
The client and the pharmacist can sit down together;
They can talk at normal speaking volumes without being overheard by staff or
customers; and
The client can rest there arm on a table/ bench at a suitable height, (see
measuring Blood Pressure)
The area is clearly signed as a private consultation room
If possible, be a quiet area
Tip: Consider what your consultation room looks like from the clients’ perspective.
Does it look like a clean, professional and safe environment? If you store excess
stock etc. in the consultation room you may need to consider storing this elsewhere.
Materials
The pharmacy will be provided with client information leaflets to support the delivery
of the service (see Appendix One)
Further supplies of British Heart Foundation (BHF) leaflets can be ordered from the
BHF. This can be done through the BHF website
http://www.bhf.org.uk/publications.aspx) or by phoning the order-line on 0870 600
6566.
Training
All pharmacists and accredited Pharmacy technicians providing the service will be
required to attend a training event that will include,
The rationale for the provision of the service
Management of Hypertension
Management of Atrial Fibrillation
Training on the use of the devices provided to measure blood pressure and
screen for Atrial fibrillation
The pathways identified for those clients identified with hypertension or
demonstrating AF.
Resources available to support the service
Requirements for reporting the outcomes of the service
Pharmacists and accredited Pharmacy technicians providing the service will be
required to complete the post workshop e –assessment on Hypertension provided
by CPPE.
In addition will be visited staff from Microlife who will be able to offer additional
Preparing to deliver the service
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support staff training on the operation of the BP monitoring devices.
It may be appropriate for those support staff deemed competent to do so by the
pharmacist to perform the initial Blood pressure test and then direct the client to the
pharmacist for interpretation of result and on-going management. To ensure
consistency in service delivery, The pharmacy must have a Standard Operating
Procedure (SOP) in place to support the delivery of the Service. SOPs should detail
the operational delivery of the Hypertension/ AF screening service in accordance
with the Service Specification service manual and service level agreement.
The lead Pharmacist within each pharmacy should determine which staffs are appropriately trained and competent to carry out the blood pressure measurements.
A British Hypertension Society (BHS) DVD video can be downloaded from the BHS website to support training and assessment of competency. (http://www.bhsoc.org/index.php?cID=162). This may also be accessed via You-Tube for those using tablet devises (http://youtu.be/XBK_Xoeqp8w)
Standard Operating Procedures
The provider must have Standard Operating Procedures (SOPs) in
place to support the delivery of the Service . SOPs should detail the operational
delivery of the Hypertension/ AF screening service in accordance with the Service
Specification service manual and service level agreement. The SOPs should
include
Client Engagement
Blood Pressure Measurement
Ambulatory Blood pressure measurement
Interpretation of results
Professional Indemnity Insurance
As outlines in the Service Level agreement, The Provider and the accredited
pharmacists must notify their professional indemnity insurers and maintain
adequate insurance cover for their participation in this service.
PharmOutcomes®
PharmOutcomes is a web-based system which helps community pharmacies provide
services more effectively and makes it easier for commissioners to audit and manage
these services. By collating information on pharmacy services it allows local and
national level analysis and reporting on the effectiveness of commissioned services,
helping to improve the evidence base for community pharmacy services
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PharmOutcomes® will be used in this service as a tool to
Capture details about the service delivered to each client.
Facilitate the transfer of Client information to the GP where appropriate.
Arrange payment to the contractor for delivery of the service.
Ensure that you have the log in details for PharmOutcomes as this is being used to
capture the Blood Pressure Drop In data. It may be a good idea to familiarise
yourself with the service on PharmOutcomes and the information that is required to
complete a record before you need to use the system (please do not add a test client
as this will trigger a false claim).
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For the service to be a success the whole pharmacy team will need to proactively promote and offer tests from May 2016.
Actions required by the pharmacy
Discuss the service with the whole pharmacy team.
Explain the aim and target customers for the service.
Agree how pharmacy staff will signpost suitable customers into the service.
Check all the pharmacy team know about the main messages about blood
pressure, the risks of high blood pressure and lifestyle messages regarding
blood pressure. This will help when discussing the service with customers.
Display promotional material provided to highlight the service to customers.
Identify key staff that can be trained to support the delivery of the service by
performing the initial blood pressure screen.
Remember, high blood pressure rarely makes people feel ill and there are usually no symptoms. It greatly increases the risk of cardiovascular disease, in particular heart attack, stroke and heart failure, and unfortunately often goes undetected until an acute event occurs. There are over 5 million adults in England living with undiagnosed high blood pressure, so early detection is key.
In order to promote the service each pharmacy will be provided with
Posters
Leaflets
Showcards
Badges In addition to promotional material provided to the pharmacies taking part, promotional material will be distributed to local GP practices. The service will also be promoted through local radio and media sources.
Service Promotion
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A
In order for the campaign to be a success, the whole pharmacy team will need to be pro-active in offering blood pressure measurement to all customers and clients who appear to fall into the over 40 age group. This should include:
Proactively initiating discussions with customers Displaying posters and leaflets within the pharmacy and highlighting these
to people visiting the pharmacy
Targeting those collecting a prescription (you’ll know if they are over 40 and can exclude those on an antihypertensive)
During another service – MUR, NMS, Stop Smoking Service etc.
The key facts about high blood pressure can be used when introducing the topic with customers. The following phrases may be useful when introducing the topic.
Engagement questions
“We are offering all customers over 40 a free blood pressure check. Would you like to know your blood pressure?”
“One in every 9 adults has high blood pressure without even knowing it. Would you like a free blood pressure check?”
“High blood pressure is estimated to cause over 20% of heart attacks and 50% of strokes. Those with high blood pressure rarely have symptoms. Would you like a
free blood pressure check today?”
Patient Engagement and Screening
Key steps
Proactively offer a free blood pressure test to all customers who appear to be over 40
Confirm the client is not excluded from the service.
Are you aged under 40.
Are you resident outside Halton
Have you had a blood pressure test within the last 6 months
Have you already been diagnosed with
• High blood pressure (or are on treatment for high blood pressure).
• Atrial Fibrillation
• Diabetes
• Chronic Kidney Disease
• Angina
• Stroke
• Transient ischaemic attack
• Heart failure
• Myocardial infarction.
If the client answers yes to any of the questions above, they are excluded
from the service. Explain to the client that they don’t meet the criteria for a
check.
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Counselling points What is blood pressure? Blood pressure is the pressure of the blood in your arteries. You need a certain amount of pressure in your arteries to keep the blood flowing around your body. Your heart pumps blood around the body through the arteries, by contracting and relaxing. The pressure of blood flowing through the arteries varies at different times in the heartbeat cycle.
What is high blood pressure? High blood pressure develops if the walls of the larger arteries lose their natural elasticity and become rigid, and if the smaller blood vessels become narrower. The higher your blood pressure, the higher your risk of health problems. A normal blood pressure reading is less than 140/90mmHg, if your blood pressure is higher than that during today’s reading we will suggest that you come back for a follow up check.
Why is high blood pressure harmful? Having high blood pressure greatly increases your risk of having a heart attack or stroke. It can also put strain on the heart so that it becomes less efficient at pumping blood around the body. If high blood pressure is left untreated for a long time, it can lead to a strain on your heart and other health problems, for example kidney problems and even damage to your sight.
What is Atrial Fibrillation?
Atrial fibrillation (AF) is the most common type of abnormal heart rhythm. An abnormal heart rhythm is also known as an arrhythmia. People with AF have an irregular and sometimes fast pulse, although you may also have a slow pulse rate. Your heart’s pumping action is controlled by tiny electrical impulses produced by a part of the right atrium called the sinus node. The sinus node is sometimes called your heart’s ‘natural pacemaker’. Atrial fibrillation happens because, as well as the sinus node sending out regular electrical impulses, different places in and around the atria (the upper chambers of the heart) also produce electrical impulses, in an uncoordinated way. These multiple impulses make the atria quiver or twitch, which is known as fibrillation. Why is Atrial fibrillation harmful? Having atrial fibrillation increases the risk of developing a blood clot inside the chambers of the heart. This is because the AF disturbs the normal flow of blood through the heart, causing turbulence. The turbulence causes the blood to form small clots. If a clot forms in your heart, it can travel through your blood stream to your brain and cause a stroke. Sometimes AF can make the heart muscle less efficient at pumping blood around your body. This is what makes some people with atrial fibrillation feel unwell or tired.
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B Introduction and client information Key steps
Move into the consultation room where the blood pressure measurements are to be taken.
Welcome discussion – take a moment to help the client relax and explain what they can expect in the next few minutes (some opening questions, BP measurement, explanation of their reading, and a discussion around lifestyle).
Complete client consent and lifestyle questions as detailed in the PharmOutcomes® data collection pro-forma.
Record details of client BP consultation on Pharmacy electronic patient medication record.
If the member of the pharmacy team who initiated the conversation is not trained to be able to take blood pressures they should transfer the client to a suitably trained member of staff.
If you didn’t undertake the initial engagement and screening with the client introduce yourself and explain that you will be taking the blood pressure.
Move to consultation room to carry out the blood pressure measurement.
It is important that those having a blood pressure taken are relaxed and have been seated for a few of minutes before the readings are taken. The introduction and client information section allows for this to happen.
Explain that the information recorded will be shared with the clients GP, and ensure they
consent to take part in the service.
Explain the consultation will entail:
• Some opening questions • Measurement of the blood pressure and screening for Atrial Fibrillation • Explanation of their reading • A discussion around lifestyle
You may wish to discuss what blood pressure and AF are and why either condition may be harmful. You may wish to use the resources provided as part of this service to help with this discussion.
Complete the initial sections of the PharmOutcomes® data collection pro-forma which include asking clients about:
Smoking Status Height/Weight/BMI Levels of Physical Activity using the General Practice Physical Activity
Questionnaire (Appendix Three)
Introduction and client information
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Client
C Measure and interpret blood pressure
It is essential that the blood pressure measurement taken is accurate by following the procedure below carefully so that the measured blood pressure is quality-assured and can be relied on by the person being tested and their GP. This procedure has been compiled from British Hypertension Society guidancexi xii and NICE Recommendations
Ensure client has had 5 minutes to relax before commencing testing (can include calm waiting time as well as the introduction discussion) before carrying out the blood pressure test.
The client should: Be seated in a quiet place if possible Be still and silent whilst the reading is taken – talking and moving both affect
accuracy Ideally not have a full bladder (this means they will be less relaxed), not have
exercised or had caffeine, nicotine or a large meal recently, as these can temporarily raise blood pressure – when engaging clients during their visit to the pharmacy this may not always be possible if the visit was unplanned. However if they are required to call back for subsequent visits then these points should be considered.
Wear loose clothing on their upper arm or remove arm from sleeve.
Cuff size: Ensure the correct cuff size is used – this is determined by the arm circumference as in table below. The bladder inside the cuff should encircle 80% of the top of the arm. If the cuff is too big the reading will be falsely low, if it is too small the reading will be falsely high.
Watch BP Cuff Sizes
S
M*
M/L
L
L-XL*
(cm)
17-22
22-32
22-42
32-42
32-52
A cuff size guide is included with the devices. This should be used to confirm the correct cuff size for each client. *The cuffs supplied as part of the service are medium and large /extra large. Patients falling outside this size range should be referred to their GP practice for testing.
Measuring Blood Pressure
Key steps
Ensure client has had 5 minutes to relax before commencing testing.
Measure the blood pressure in both arms and record both readings. o Use the arm with the highest reading if further BP
measurements are needed.
Complete the recorded measurements on the PharmOutcomes® data collection Pro-Forma
Client advice and further action to be confirmed by Pharmacist
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The technique:
Ensure your hands are clean.
Ask the person being tested if they would prefer either of their arms not to be used – for example because of previous trauma or surgery
The cuff should be placed two to three centimetres above the elbow joint. The whole cuff should be placed directly next to the skin and clothing above the cuff should be loose – remove arm from sleeve if necessary
The centre of the bladder in the cuff should be positioned over the line of the artery. The cuffs have this marked on them
The arm should be supported at the level of the mid sternum (heart level). If the arm is below heart level it can lead to an overestimation of the systolic and diastolic pressure by about 10 mmHg. Having the arm above heart level can lead to underestimation.
The measurement:
Measure the blood pressure in both arms and record both readings. o If the difference in readings between arms is more than 20 mmHg
systolic or 10mmHg diastolic, the pharmacist should advise client to visit GP for further investigation routinely.
o Use the arm with the highest reading if further BP measurements are needed.
Complete the recorded measurements on the PharmOutcomes® data collection Pro-Forma
Record details of client BP consultation on Pharmacy electronic patient medication record. ( see Records)
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in the blood pressure
In communicating the result it is important to give enough information, to encourage the person being tested to take appropriate action and to avoid causing inappropriate alarm. Explain what blood pressure readings mean to all clients and then give the information specific for their blood pressure reading.
The following information may be useful when explaining blood pressure readings as would the British Heart Foundation Blood Pressure information booklet to help with this discussion.
Explain the Blood pressure results and next steps
Key steps
The pharmacist is responsible for explaining the results and next steps for the patient.
In communicating the result it is important to give enough information, to encourage the person being tested to take appropriate action and to avoid causing inappropriate alarm.
Be clear that if a client’s BP is raised it does not mean that they have a diagnosis of high blood pressure (Hypertension) – they will need further tests to establish this.
Explain what the client’s blood pressure readings mean.
Counselling Points
Blood pressure Blood pressure is the pressure of the blood in your arteries. Blood pressure is written as two numbers – for example, 120/80mmHg. (‘mmHg’ is the unit used for measuring blood pressure. It stands for millimetres of mercury.) The first number is the systolic pressure and the second is the diastolic pressure.
Systolic blood pressure is the highest level your blood pressure
reaches. This is when your heart contracts and blood is forced through the arteries.
Diastolic blood pressure is the lowest level your blood pressure reaches. This is when your heart relaxes between each beat.
Understanding how to manage your blood pressure allows you to take more control of your condition, and also helps prevent complications.
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Why is high blood pressure harmful? Having high blood pressure greatly increases your risk of having a heart attack or stroke. It can also put strain on the heart so that it becomes less efficient at pumping blood around the body. If high blood pressure is left untreated for a long time, it can lead to a strain on your heart and other health problems, for example kidney problems and even damage to your sight.
What happens next if my blood pressure is high? We may suggest that you have a 24 hour blood pressure monitor fitted to take home, or home blood pressure monitoring, before confirming that you have raised blood pressure. If you then need treatment for high blood pressure, sometimes lifestyle changes are enough (e.g. salt and alcohol intake, weight loss and exercise), and sometimes you need to take medicines as well. The important thing is not to ignore a blood pressure reading that is raised because if you do have high blood pressure, treatment with lifestyle change or medicines can dramatically reduce the risks to your health.
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Consider the next steps
The specific action to take depends on the blood pressure measurements and is outlined below. The Pharmacist is responsible for explaining the results and next steps for the patient.
Results detected Threshold Actions required
Atrial Fibrillation detected. (AF icon displayed on meter)
Not applicable Client will be advised of the result and advised to make an appointment to see their GP within one week. Advice given recorded on Pharmoutcomes® and PMR. Paper copy given to patient to take to GP
BP detected in Right and Left arm is significantly different
The difference in readings between arms is more than 20 mmHg systolic or 10mmHg diastolic
Client will be advised of the result and advised to make an appointment with their GP for follow up within one week. Advice given recorded on Pharmoutcomes® and PMR. Paper copy given to patient to take to GP
BP is very low/ undetectable
Lower than 90/60 Client will be advised of the result and to advised make an appointment to see their GP within one week. Advice given recorded on Pharmoutcomes® and PMR. Paper copy given to patient to take to GP
BP is Normal. (Single reading)
90-139/60-89 mm/Hg
BP is normal maintain healthy lifestyle. **Client lifestyle advice provided. Referral to Health Improvement team offered for clients identified with risk factors for cardiovascular disease. Test should be repeated every five years. Advice given recorded on Pharmoutcomes® and PMR.
BP is raised – first visit
140-179/90-109 Client advised to return for re-check of Blood pressure in one week.
Systolic BP≥180 or Diastolic BP≥110
Advise that BP is very high and requires GP same day or A&E/Urgent Care. Advice given recorded on Pharmoutcomes® and PMR. Paper copy given to patient to take to GP/A&E/Urgent Care
BP is Normal. Second Visit (Third visit required if substantially different).
90-139/60-89 mm/Hg
BP is normal maintain healthy lifestyle. Client lifestyle advice provided. Referral to Health promotion offered for clients identified with risk factors for cardiovascular disease. Consider a repeat in a year Advice given recorded on Pharmoutcomes® and PMR.
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BP is raised (after second or third visit)
140-179/90-109 Ambulatory BP monitoring offered***. Home Blood pressure monitoring may be offered if ambulatory device is not acceptable for the client. Advice given recorded on Pharmoutcomes® and PMR.
Systolic BP≥180 or Diastolic BP≥110
Advise that BP is very high and requires GP same day or A&E/Urgent Care. Advice given recorded on Pharmoutcomes® and PMR. Paper copy given to patient to take to GP/A&E/Urgent Care
***Clients demonstrating a raised Blood Pressure on two or three occasions over a few
weeks will be offered Ambulatory monitoring. An explanation of what this will involve
should be offered to the client and a suitable time arranged for the ambulatory monitoring
to take place.
The client should be advised that
It is recommended that you do not drive for the duration of your monitoring
You should wear loose clothing, preferably a short sleeved top. The monitor will be fitted underneath your top.
Clients requested to return for ABPM will be advised to wear a light sleeveless vest/ T- shirt so the monitor can be fitted discreetly.
Clients should also wear a belt to which the monitor can be attached.
Preferably avoid showering or bathing during the period of measurement.
Clients should be provided with an ABPM client information leaflet. (See Resources- Appendix One)
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Re-checking Clinic Blood Pressure
Key Steps
Clients may be requested to return to the pharmacy to have their Blood pressure checked after a week.
Blood pressure should be measured as per the processes described in o Introduction and client information o Measuring Blood Pressure o Explaining results and next steps
Blood pressure should be measured on the arm in which the highest BP was previously demonstrated. ( As recorded on Pharmoutcomes® and PMR)
Complete the recorded measurements on the PharmOutcomes® data collection Pro-Forma and on the pharmacy PMR.
Client advice and further action to be confirmed by Pharmacist
Clients requested to return for ABPM will be advised of what this will involve and what they should wear.
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It is essential that the blood pressure taken is accurate by following the procedure below carefully so that the measured blood pressure is quality-assured and can be relied on by the person being tested and their GP. This procedure has been compiled from British Hypertension Society guidance and NICE Recommendations The Pharmacist/ Pharmacy Technician must:
be familiar with the equipment ( Full operational guidance is provided with the device)
know the calibration procedures for the device
know the normal ranges of blood pressure during the day and night
be aware of the factors influencing the diurnal pattern
Allow the necessary time to instruct the client so as to obtain as many measurements as possible (aiming for 100%) during the recording period
The ABPM must be comfortable for the client to wear. An appropriately sized cuff containing the correct size bladder must be used. See previous information on Cuff Size. A cuff measuring guide is provided with the equipment
Clients for ABPM must be capable of coping with and caring for the recorder
Apart from driving, Normal activity should be maintained during ABPM except when measurements are being made. Clients should be advised not to drive during the monitoring period.
The clients arm should be still and held at heart level during measurement
Recordings are usually programmed for every 30 minutes during the day (07.00 – 22.00) and 60 minutes at night (22.00 to 07.00). These times should be changed if the client works at night
You may wish clients to keep a diary of activities and symptoms during the recording period. (See Resources). If recording overnight, they must state when they went to bed, when they woke up and what time they took their medication, including over-the-counter medicines
Clients should be provided with an ABPM client information leaflet. (See Resources- Appendix One)
Performing Ambulatory Blood Pressure Monitoring (ABPM)
Key Points
Prior to using the Microlife WatchBP 03 ambulatory blood pressure monitor the pharmacy will need to install the device software.
ABPM will be performed by accredited pharmacy technicians or pharmacists only
Blood pressure should be measured on the arm in which the highest BP was previously demonstrated.
Complete the recorded measurements on the PharmOutcomes® data collection Pro-Forma and Pharmacy PMR
Patient advice and further action to be confirmed by Pharmacist
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Initialising the Monitor
Initialise according to manufacturer’s instructions
Prior to fitting the monitor
It would be good practice to offer the client a chaperone whilst fitting/removing the ABP monitor.
Request that the client completes the ‘LOAN OF AMBULATORY BLOOD PRESSURE MONITOR’ form (Appendix Five)
Prior to attaching Monitor (ABPM),ask client the following questions: o Does the client take Warfarin tablets? If ‘yes’ advise client of increased risk of
bruising to upper/lower arm and that if they see this occurring, they should discontinue wearing the ABPM.
o Are there any problems you are aware of which would prevent the client from wearing an ABPM on a particular arm?(e.g. arm affected by a stroke or mastectomy). If ‘yes’ advise client to wear ABPM on the unaffected arm.
o Does the client have tight-fitting jewellery to the arm chosen for ABPM i.e. watch, bracelet, rings? If ‘yes’ advise client to remove them during the procedure.
o Ensure the client is aware of health & safety implications re monitor, cuff and tubing and work/leisure activities. Clients should be advised to avoid driving whilst ABPM is being worn.
o Is the client allergic to latex? If ‘yes’ ensure latex free cuff is fitted. (Microlife cuff bladders are latex and PVC free)
Putting the Monitor on Client
Switch monitor ‘on’ and place inside pouch. Show the client the on/off switch and explain the display screen before putting in the pouch.
Place cuff on non-dominant arm unless there is a 20/10mmHg difference between arms in which case use arm with higher reading, or a clinical reason not to use a particular arm (eg lymphoedema). Line up the arrow on the cuff near the brachial artery. Explain, as you are fitting the cuff, about the position and how to adjust the cuff if it slips.
Use an appropriately sized cuff (with clothing removed, measure arm circumference half way between tip of shoulder & elbow).
Use a large cuff extra large or small cuff according to manufacturer’s instructions. See previous instructions on cuff size.
Pull cuff Velcro until it’s a firm fit. Wind tubing around the back of the clients’s neck and down his/her front and attach tubing to the monitor.
To start the readings
Do one or two readings in clinic to make sure it is working; so you can explain to the client how it works and how it will feel. Explain about the alert mechanism before and after the reading as you are doing this.
Switch monitor ‘on’ and check the time is showing. Demonstrate to client following manufacturer’s instructions. The cuff will inflate, and then deflate.
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If the first reading is successful, ask the client to put his/her shirt back on, feeding tube through the shirt opening. Attach Monitor to belt and waist, making sure tube isn’t kinked.
If “Error” occurs, check the ABPM Manual
Check batteries are working.
An error may occur if: o The client’s blood pressure is very high or very low o If the heart beat is irregular o If the client is very obese. Battery life may be compromised and the cuff
may take considerably longer to inflate o If the cuff or monitor is faulty o Other as per manufacturer’s checklist
Explanation & Instructions to give to client
The operator should aim to achieve 100% successful readings. This is achieved by
careful explanation of the procedure to the client and the client being able to carry out the
instructions. Clients should receive verbal and written procedure training on the ABP
monitor.
Tell the client they must not talk or move during the measurement
Tell them to stand or sit still with their arm supported during the measurement. (They can support their arm with their other arm if they are standing or rest it on a desk, table, cushion or pillow when sitting)
The cuff must be at heart level whenever a measurement is done
Tell them the monitor beeps during the day to warn them the cuff will start inflating a few seconds later
Tell them it will then deflate. If the reading is successful it will beep (or other alert) again
It may be unsuccessful if they are on a train, getting on/off a bus, or talking. If there is no apparent reason for the error tell them to check the cuff is in the correct position and has not slipped, check the tubing has not kinked or that the tubing has not come apart
Show them how to put the tubing back on the monitor if it should come apart
If they are wearing the monitor at night, tell them to take the monitor off their belt and put on the same side as the cuff, so that none of the tubing is around their neck. Either put under a pillow or safely on a bedside table away from water glass
Give the client a diary to complete. (See resources – Appendix one). They must document the time they went to bed and time they woke up
Ask them to write in the diary the names, doses and times of any medicines (including over-the-counter) they took over the 24 hour period
Give them an instruction sheet on care of monitor. Tell them they must not shower, or allow the monitor to get wet
Tell the client to return the monitor to the pharmacy at the instructed time the next day
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Removing the monitor
Explain to the client at what time the monitor should be removed and arrange appointment for them to return to the pharmacy.
Explain to the client how to take the monitor off and turn it off at home.
They should complete the diary if appropriate and return with the monitor
Downloading the data from the monitor
The Results of the ABPM can be downloaded as a PDF according to the manufacturers
instructions
Complete the recorded measurements on the PharmOutcomes® data collection Pro-Forma and the pharmacy PMR
Explaining the results and next steps for the client.
Ambulatory Blood pressure performed
If Initial blood pressure is above or equal to 140/90 mmHg, but ABPM average is below or equal to 134/84 mmHg.
BP is normal maintain healthy lifestyle. Client lifestyle advice provided. Referral to Health promotion offered for clients identified with risk factors for cardiovascular disease. Retest may be offered to support management of adjustable risk factors. Client should be advised to make an appointment with their Practice Nurse within two to three weeks, as NICE also recommends follow up investigations for target organ damage
If Initial blood pressure is above or equal to 140/90 mmHg, and ABPM average is above or equal to 135/85 mmHg. The decision to treat this level of hypertension depends on an assessment of the total cardiovascular disease risk
Client will be advised of the result and advised to make an appointment to see their Practice Nurse within two weeks.
Key steps
The pharmacist is responsible for explaining the results and next steps for the patient.
In communicating the result it is important to give enough information, to encourage the person being tested to take appropriate action and to avoid causing inappropriate alarm.
Explain what the client’s blood pressure readings mean.
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If Initial blood pressure was above or equal to 160/100 mmHg, and ABPM average is above or equal to 150/95 mmHg, or there is isolated systolic hypertension with a systolic blood pressure of 160 mmHg or higher.
Client will be informed of the result and advised to make an appointment to see their GP within one week.
Record the advice given on the on the PharmOutcomes® data collection Pro-Forma and the clients record on the Pharmacy PMR.
GPs will be notified of the results of the ABPM with a secure email via the PharmOutcomes® portal. The Client will also be provided with a printed copy to take to the GP.
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.
E Lifestyle discussion on maintaining a healthy blood pressure
Engage in a brief discussion about the clients current lifestyle habits (diet, smoking, physical activity, alcohol, weight). This discussion should be in line with your normal practice and the information that you provide following a routine pharmacy brief intervention.
The advice can be reinforced with written information and/or links to online resources.
The Halton Health Improvement Team offers a wide range of services to help improve health and wellbeing, including support to quit smoking, lose weight and get fit and healthy. Referral to the services offered may be provided using Appendix Four. Clients referred to Halton Health Improvement team will be contacted by the team discuss further support available. The information below may assist you in the information to provide and the relevant
signposting information.
Lifestyle discussion on maintaining a healthy blood pressure
Key steps
Engage in a brief discussion about the clients current lifestyle habits (diet, smoking, physical activity, alcohol, weight).
Provide general advice on improving lifestyle and reducing risk factors in line with the usual advice and information provided.
Reinforce this advice where necessary with written information and/or links to online resources.
Signpost to support services as required using - Appendix Four Health Improvement team referral.
Record any advice and signposting provided on the PharmOutcomes® data collection Pro-Forma
The effect of diet
Salt raises your blood pressure. The more salt you eat, the higher your blood
pressure. Aim to eat less than 6g of salt a day. A lot of foods we buy in supermarkets
have added salt – check the labels. Eating a low-fat diet that includes lots of fibre (for
example, wholegrain rice, bread and pasta) and plenty of fruit and vegetables has
been proven to help lower blood pressure. Aim to eat five portions of fruit and
vegetables every day.
Caffeine: drinking more than four cups of caffeine-rich drinks a day may increase
your blood pressure. If you are a big fan of coffee, tea, cola and some energy drinks,
consider cutting down.
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Exercise Being active and taking regular exercise lowers blood pressure by keeping your heart and blood vessels in good condition. Regular exercise can also help you lose weight, which will also help lower your blood pressure. Adults should do at least 150 minutes of moderate-intensity aerobic activity (e.g. cycling or fast walking) every week. For it to count, the activity should make you feel warm and slightly out of breath. Physical activity can include anything from walking to gardening, housework to sport. Get more ideas on being active from www.nhs.uk/Livewell/fitness/Pages/Activelifestyle.aspx.
Weight Being overweight forces your heart to work harder to pump blood around your body, which can raise your blood pressure. Find out if you need to lose weight with the BMI healthy weight calculator. If you do need to lose some weight, it is worth remembering that just losing a few pounds can make a big difference to your blood pressure and overall health. Get tips on losing weight safely from www.nhs.uk/LiveWell/Loseweight/Pages/Loseweighthome.aspx
Smoking
Smoking doesn't directly cause high blood pressure but it puts you at much higher
risk of a heart attack and stroke. Smoking, like high blood pressure, will cause your
arteries to narrow. If you smoke and have high blood pressure, your arteries will
narrow much more quickly and your risk of a heart or lung disease in the future is
dramatically increased. Get help to stop smoking as you are more likely to quit.
Alcohol
Regularly drinking alcohol above what the NHS recommends will raise your blood pressure over time. Knowing your units will help you stay in control of your drinking. To reduce your risk of harming your health if you drink most weeks:
men and women are advised not to regularly drink more than 14 units a week spread your drinking over three days or more if you drink as much as 14 units
a week
Fourteen units is equivalent to six pints of average strength beer or 10 small
glasses of low strength wine. Find out how many units are in your favourite tipple, track your drinking over time and get tips on cutting down at www.nhs.uk/livewell/alcohol/pages/alcohol-units.aspx . Alcohol is also high in calories, which will make you gain weight. This will also increase your blood pressure.
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F Closing
We ask that pharmacies take this opportunity to advertise the NHS Health Check so that people understand that there is a more comprehensive health check on offer and they should take up the offer of a health check if they are invited by their GP surgery.
NHS Health Check
“If you are between 40 and 74, every 5 years you will be invited to have an NHS Health Check. This is a different and more comprehensive check-up than our test today. This may be carried out at your GP practice or elsewhere. The health check helps you to measure your risk of developing diabetes, heart and kidney disease and stroke and to prevent or delay the onset of these conditions. Make sure you book your appointment when you receive the invitation.”
Closing
Key steps
Agree follow up appointments if required. Provide the client with an appointment card.
Clients advised to make a follow up appointment with their Gp should also be given a paper copy of the information that will be sent to the GP to take with them.
Remind the client that the results of the blood pressure test will be forwarded securely to their GP to update their medical records
Thank the client for their taking part in the Service
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The information gathered about the client during the consultation should be promptly recorded on PharmOutcomes®, ideally during the consultation.
For those pharmacies that do not have access to a computer terminal in the consultation room a paper consultation pro-forma may be used. The information should be transferred to the PharmOutcomes® promptly, ideally the same day and within 48 hours of the blood pressure measurement.
A record of the consultation should also be made on the contractors electronic client medication records. The information recorded should include
Smoking Status
Alcohol Consumption
Exercise level
Current weight/BMI
Current BP- stating on which arm this was measured.
Lifestyle advice given
Follow up actions required.
For those clients that have been requested to return for follow up BP testing, paper consultation pro-formas may be retained in the pharmacy in a safe and secure manner and protected from unauthorised access (in line with the NHS guidance for record retention). When all actions are complete and data has been recorded on PharmOutcomes® and the pharmacy electronic client medication record, paper records should be shredded / destroyed as confidential waste.
PharmOutcomes
PharmOutcomes® can be accessed at: www.pharmoutcomes.org.uk
All pharmacies have previously been sent a user name and password details for the PharmaOutcomes®.
If you have misplaced or lost your log on details please contact the PharmOutcomes® helpdesk
Go to www.pharmoutcomes.org.uk and click the Help button
Call the Helpdesk on 0330 660 0689 and leave a message clearly stating your location, your phone number and a brief description of the problem you are experiencing
User Guides There are several guides to assist you with using the PharmOutcomes®. These can be accessed by clicking the help tab. Guides are available for various topics such as creating new users.
Records
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Recording Activity Service activity should ideally be recorded during the consultation or alternatively input after the consultation. The Data Collection form captures all the information that is required. PharmOutcomes will not allow you to save the data unless all the information is recorded so please ensure that you fully complete all the questions on the Data Collection form.
Log onto PharmOutcomes.
Click the Services Tab.
Find and click on BP/AF screening and select the correct intervention
Enter the data. Click Save. This will save the data onto the system and also trigger a
claim.
A secure email will be sent to the clients GP with the information the GP requires to update their medical record.
Patients advised to make a follow up appointment with their GP should also be given a paper copy of the PharmOutcomes® record.
It may be a good idea to familiarise yourself with the service on PharmOutcomes® and theinformation that is required to complete a record before you need to use the system (please do not add a test client as this will trigger a false claim).
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ng the campaign Fees paid for the screening services offered will be as followed.
Initial Blood Pressure & AF Screen* £ 5
Repeat monitoring for clients with initial elevated BP readings*
£5
Ambulatory Monitoring Service ** £40
*Initial BP monitoring may be supported by pharmacy support staff.
** Ambulatory monitoring may be supported by registered pharmacy technician accredited to the service.
In both cases interpretation of results and on-going advice and support remains the responsibility of the accredited pharmacist
Payments will be based on the data recorded on the PharmOutcomes® website
Payments will be made based on the data extracted from PharmOutcomes® website
on the last day of each month.
Key Contacts
Payment
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Resource Details Where can I obtain this from?
Blood Pressure Booklet (BHF)
This booklet is for people who want to know more about high blood pressure. It explains what high blood pressure is, why it is so important to control high blood pressure, what you can do to help and what medicines are used to treat it.
BHF website (http://www.bhf.org.uk/publications.aspx) or order via the BHF order-line on 0870 600 6566
Atrial Fibrillation Booklet (BHF)
This booklet is designed for people with atrial fibrillation, useful also for family and friends. It describes the heart's normal rhythm, what atrial fibrillation is, diagnosis, complications, and different types of treatment.
BHF website (http://www.bhf.org.uk/publications.aspx) or order via the BHF order-line on 0870 600 6566
10minutes to change your life booklet (BHF)
A simple guide for people who have high blood pressure, or have been told they are at risk of getting high blood pressure.
BHF website (http://www.bhf.org.uk/publications.aspx) or order via the BHF order-line on 0870 600 6566
Keep your heart healthy (BHF)
This booklet explains that making changes to your lifestyle can help you look after your heart and reduce your risk of developing certain heart conditions, such as coronary heart disease (angina and heart attack) and having a stroke.
BHF website (http://www.bhf.org.uk/publications.aspx) or order via the BHF order-line on 0870 600 6566
ABPM explained
Client information leaflet explaining what to expect from ABPM
British Hypertension society website http://bhsoc.org/index.php/download_file/view/266/161/
Appendix One – Resources to support delivery of the service
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Resource Details Where can I obtain this from?
ABPM Client Diary
Diary for client to record activity during ABPM
British Hypertension society website http://bhsoc.org/index.php/download_file/view/267/161/
ABPM Clinic Checklist for Fitting ABPM
Checklist to use when fitting ABPM. Matches Pharm Outcomes template
British Hypertension society website http://bhsoc.org/index.php/download_file/view/268/161/
SOP for fitting ABPM
SOP that can be adapted for pharmacy use
British Hypertension society website http://bhsoc.org/index.php/download_file/view/269/161/
How to use a digital Blood pressure meter
SOP that can be adapted for pharmacy use
British Hypertension society website http://bhsoc.org/index.php/download_file/view/699/132/
Lifestyle leaflets Leaflets to support the core messages of the service e.g. smoking cessation, exercise, weight management
client.co.uk (excellent resource for a number of health information leaflets (http://www.client.co.uk/health
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Halton CCG Screening for Hypertension and Atrial Fibrillation in community
pharmacy
I consent to the pharmacy:
Screening me for AF or Hypertension/Hypotension
Providing advice to improve my health.
Liaising with my GP around my health needs.
Liaising with appropriate healthcare professional around my health needs.
I consent for the information obtained during the review to be shared with:
My doctor (GP) to help them provide care to me.
Any appropriate healthcare professional to help them provide care to me
I accept that my information will be recorded on the PharmOutcomes® system and my
data will stored in line with Level 3 requirements published by the NHS for 3rd party
commercial providers and to be compliant with the NHS code on confidentiality.
I acknowledge to evaluate the service anonymised data may be shared with:
NHS England (the national NHS body that manages pharmacy, Halton CCG and
other health services)
Halton clinical commissioning group CCG) to ensure this service is being provided
in line with the service level agreement by the pharmacy.
Name ………………………………………………………………………………..
Date…………………………………………………
Signature ………………………………………………………………………….
Appendix Two– Consent Form
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Screening tool used in routine general practice to provide a simple physical activity index.
The general practice physical activity questionnaire (GPPAQ ) is a validated screening tool, used in primary care to assess the physical activity levels of adults (16 to 74 years). It provides a simple, 4 level physical activity index (PAI). Practitioners can use this index to help them decide when to offer interventions to increase physical activity. The NICE guidance states that if (through validated screening tool, such as GPPAQ) an individual is identified as less than active, practitioners should offer a brief intervention in physical activity. Which should include the following recommendations:
When providing physical activity advice, primary care practitioners should take into account the individual’s needs, preferences and circumstances.
They should agree goals with them. They should also provide written information about the benefits of activity and the local opportunities to be active.
Where appropriate offer a referral into a condition specific or exercise on referral programme, if they exist in your area.
GPPAQ – Full guidance document
GPPAQ_-_guidance.pdf
GPPAQ – Questionnaire PDF
GPPAQ_-_pdf_version.pdf
GPPAQ – Questionnaire EXCEL
Copy of GPPAQ_-_excel_version.xlsx
Appendix Three – Levels of Physical Activity using the General Practice
Physical Activity Questionnaire
39
-Resources to support delivery of the
Appendix Four – Health Improvement Referral form
40
LOAN OF AMBULATORY BLOOD PRESSURE MONITOR
PHARMACY TO PATIENT FORM Name: Tel no: Address: (Please indicate proof of identification provided) …………………………………………… Pharmacy Date: Description of equipment borrowed Serial numbers 1. ………………………………… ……………….
Please circle cuff provided Medium Large Extra Large Specified return date: ………………. Declaration I agree to the safekeeping of the equipment detailed above and to return all items on the date specified. Any loss or damage to the equipment may result in a claim for reimbursement or any reasonable costs incurred. Signed:……..……………… Authorising Signature:………………….. Print Name Print Name Pharmacy use only I confirm that the above item(s) have been returned in a satisfactory condition. Signed:…………………….
Appendix Five - LOAN OF AMBULATORY BLOOD PRESSURE MONITOR
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OF AMBULATORY BLOOD PRESSURE MONITOR
i Royal Society of Public Health, Reducing premature mortality: the role of community pharmacists
(February 2015) Available at http://www.rsph.org.uk/filemanager/root/site_assets/our_work/position_statements/rsph_pharmacy_position_23.02.2015_47774.pdf ii Public Health England. Hypertension profile: Halton CCG (Feb 2016.
http://www.yhpho.org.uk/resource/view.aspx?RID=223374 iii Public Health England. Tackling high blood pressure: From evidence into action. 2014. Available at
http://www.gov.uk/government/publications/high-blood-pressure-action-plan iv Department of Health (2013). Cardiovascular Disease Outcomes Strategy: Improving outcomes for
people with or at risk of cardiovascular disease. London: Department of Health.
v National Institute for Health and Clinical Excellence (2011). Hypertension: The Clinical Management of
Primary Hypertension in Adults. Clinical Guideline 127. London: NICE. https://www.nice.org.uk/guidance/CG127
vi Murray CJL, Richards MA, Newton JNN et al. (2013) UK Health performance: findings of the Global
Burden of Disease Study 2010. The Lancet; 381: 997-1020
vii Yusuf S, Hawken S, Ounpuu S et al. (2004). Effect of potentially modifiable risk factors
associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. The Lancet; 364: 937-52.
viii Lawes CMM, Vander Hoorn S, Rodgers A, for the International Society of Hypertension (2008).
Global burden of blood-pressure-related disease, 2001. The Lancet; 371: 1513-18.
ix National Clinical Guideline Centre (2014) Atrial fibrillation. Atrial fibrillation: the management of atrial
fibrillation. National Institute for Health and Care Excellence. https://www.nice.org.uk/guidance/CG180 x NICE medical technology guidance.MTG13. WatchBP Home A for opportunistically detecting atrial
fibrillation during diagnosis and monitoring of hypertension. January 2013. Available at http://www.nice.org.uk/guidance/MTG13
xi British Hypertension Society. Poster . Measuring Blood Pressure using a digital monitor.
http://bhsoc.org/resources/how-to-measure-blood-pressure/ xii
European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement O'Brien,E et al. Journal of Hypertension 2003, Vol 21, 5: 821-848. http://bhsoc.org/files/2113/3374/7291/ESH_recommendations.pdf
References
