Most collegiate groups define hypertensive crisis as systolic blood pressure greater than 180mmHg and/or diastolic blood pressure greater than 120mmHg and further categorized as hypertensive urgency or emergency by whether signs or symptoms of end-organ damage are present [1]. Variations in blood pressure are a natural physiologic occurrence and elevations can arise in response to stress, such as pain or acute illness. In an inpatient setting, factors such as delayed administration of home medications and hypervolemia due to intravenous (IV) fluid resuscitation can increase blood pressure [1]. In addition to the patient-specific causes of hypertension, abnormal values can be obtained by improper technique as well as errors in data entry. 

While the consequences of chronically uncontrolled blood pressure are widely known, acute management does not improve long-term outcomes [2] and there is not much data on untreated acute severe blood pressure elevations [1]. Controlling elevated blood pressure in the inpatient setting may lack any benefit and be potentially harmful. [1]. Irrespective of this evidence, widespread use of IV anti-hypertensives increases the overall cost of treatment and has caused critical drug shortages [2]. 

Several studies have shown that most of these medications are given inappropriately to patients who do not meet criteria for either sub-type of hypertensive crisis [1]. We have designed a quality improvement project that ensures that these medications are only given when indicated. Prior to program initiation, education will be provided for correctly measuring blood pressure. Using electronic medical record alerts, a user who submits vitals outside normal range must repeat measurements and enter new values. If those values are abnormal, the user will be asked to confirm associated symptoms using a checklist. A hard stop will advise notifying a physician if the information entered is consistent with hypertensive crisis.