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Table 3 Themes, subthemes and supporting quotations from pharmacists and pharmacy technicians/assistants about their experiences and practice with customers who are concerned about an elevated blood pressure reading

From: High blood pressure readings on in-store machines: a qualitative study of the perspective of pharmacy staff

Theme

Subtheme

Quotation

Definition of high BP is not based on the BP value alone

Demographics

No value, background. There is a formula to screen for hypertension and pre-hypertension. Age, history but it is hard to do in retail

120/80 is the average but it fluctuates between gender, age, weight. Depends on the person

 

Comorbidities

Depends if they don’t have any diabetes or kidney disease. If no diabetes 140/90 or if diabetic, have kidney disease or heart disease it needs to be under 130/80

 

Guideline used

Depends on which guidelines you follow. ADA guidelines look at diabetes, age. They say 140/90 for diabetics. If not ASCVD risk, if healthy 150/90 but I don't go through everything. ASCVD, JNC7, could follow those too. Controversial topic, diabetes linked to hypertension

 

BP consistently elevated

Depends…if it is a first reading or if it is always above 140/90

Pharmacists will converse with the patient and assess the situation prior to providing advice

Troubleshoot (encourage to relax and retake BP)

First I try and calm them down, try to retake their blood pressure in 5 min

Sometimes I manually check, calm them down, retake it

I tell them to relax and retake it. They could be sort of pacing, sit for 10 min then go to the machine

Have another reading. Running around, stress makes it go up sometimes

 

Review events prior to blood pressure taking

Did you walk? Have coffee?

Did they just exercise or drink coffee? Because that will elevate it. The reading is just a snapshot of that moment

 

Discuss lifestyle (diet/exercise)

Before the readings I discuss their diet and lifestyle

 

Review medical history and medications/medication compliance

I go over their diagnosis, medications, their history

Ask about medications, sometimes medications need to be added

Some have high blood pressure medications, are they using any blood pressure medications?

Are they taking medications as prescribed?

 

Assess symptoms

They have a headache sometimes. Go through all of that

I ask about symptoms, headache, that is concerning

Advice is patient specific and dependent on various patient factors

BP reading/value

Changes with whatever reading they have. If above 170 to ER. If it is lower, I give them pharmacy and non-pharmacy advice

Check with doctor unless it is really elevated then urgent care

Depending on where they stand…If it is quite high, I advise them to see their family doctor or go to urgent care. If it's not that high, come back and retake it in the afternoon

 

BP consistently elevated

He said 150/90 [BP reading], I said that's fine but if consistently high go to the doctor

If it is high all the time, I tell them to go to their doctor

 

Symptoms

Check up with family doctor if they do not feel well, tired

 

Medications/history of HTN

Tell them to follow up with their doctor if medications need to be changed

It depends [advice]. Are they on blood pressure medications?

Advice/interventions provided are multifaceted

Reassurance/education

A lot of times it is 130 or 120 and they freak out. That happens often…[I] provide hypertension education, what is high

Tell them caffeine intake can increase blood pressure if they had it a half an hour before. A full bladder can raise it too

Anything over 135 is high on the machine so they come running. “No man, it isn't high. You're fine”

The machine is not as accurate as the doctor's office. The cuff size is standard here…Blood pressure is dynamic, not just one reading

 

Monitor BP/keep logbook

Tell them to keep a log of their readings

Record blood pressure a few times

Monitor it

 

Lifestyle changes (diet/exercise)

I tell them what they can do to lower it, decrease salt, increase exercise

I tell them about how to change their diet and exercise

Do they eat salty food or any canned food? Tell them to avoid it

 

PRN medication administration

Some have blood pressure medications, fast acting that they take if their blood pressure is high. We tell them to take it

 

Seek medical attention

I advise them to see their family doctor or go to urgent care

It is better to speak with a doctor to be monitored

Make an appointment with your doctor

No store/governing body policy for pharmacists to follow when providing advice to patients with elevated in-store BP readings

Professional knowledge used to guide advice

No policy but what I know from my profession, my knowledge

No [policy], just professional judgement and obligation. If they have an elevated reading and ran out of medications I have to record their blood pressure in record if refilling blood pressure medication and I have to call the prescriber

 

Familiarity/comfort with patient guides advice

Regular patients, look at their history, medications. If not a regular patient [I] send them to urgent care to get a check up

No [policy], individualized, how much I know them. How many times they have taken it in a row [BP]? Do they have high blood pressure?

 

Follow a HTN guideline

[I] follow current guidelines but there are 3. There is no in-store policy per se, they just want us to follow one of the guidelines

No, not really [policy]. Guidelines you can follow though

 

Advice is pharmacist specific, have their own set of rules/guidelines

No, all pharmacists have their own. You may get different advice from different pharmacists

No policy. Set of rules to follow. No exercise, sitting down, no speaking, rest, no caffeine for a half hour to 1 hour before taking blood pressure

No policy. Just ask about any medications, conditions, allergies. Nothing specific [in terms of policy]

Referral process to the ED is dependent on several factors

Symptoms/presentation

Symptoms. Dizzy, not able to walk, tired, headache

If they feel their heart beat higher, you have to consider heart attack. If they are tired or don’t feel well

Someone grabbing their chest saying “I am having a stroke” I would think those patients go straight to the emergency department

Experiencing any other symptoms, lightheaded and dizzy

Symptoms, feel dizzy, feel like having a headache, tend to ask to go to emergency…have a buzzing in their ears

Headache, vision change, I suggest to go to the emergency department. See a doctor right away

 

Severity of BP value

One time it was 200/140 so I said “do you need me to call 911 for you?”

Over 180 or 190 to emergency department or urgent care

180 plus or diastolic well over 100 [to ED]

If really really elevated, stroke level…I don't know how much you know about hypertension but not everyone has symptoms when their reading is high so it depends. Someone with a high reading could be having a stroke

Doctor's office unless it is over 180, then go to the hospital. That is an emergency

Cut-off 200s. Straight to emergency, or maybe 190, close to 200. They need to see a doctor sooner than later

 

BP consistently elevated

If it is consistently high go to emerge, it is always there

 

Factors potentially contributing to elevated reading

Gather more information. They missed a dose [medication]? Had caffeine or walked far? Just talk to them

 

Access to/availability of a primary care practitioner

Urgent care or emergency department if they don't have a primary doctor

Call their prescriber, their regular doctor and see if they can order a one-time dose of something. I've had that happen before too. But if not, and over 180 or 190 to emergency department or urgent care

 

Presence of comorbidities

Sometimes it is their blood glucose reading. Like if it is over 300, call 911

 

No past medical history of HTN

If they don’t have a history [HTN] then definitely tell them they need to get it checked out now [urgent care or ED]

 

Weekday vs. weekend

One case around 180–190, called the ambulance, it was a weekend, I couldn't let her go

 

Familiarity with patient/access to drug profile

If I have their profile, I will change their medication dose [increase it] and tell them to see their doctor [as opposed to advising them to go to the ED]