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Clinical Effectiveness Group

Blood Pressure Monitoring at Home (BPM@h)

We are supporting NHS England and NHS Improvement’s national Blood Pressure Monitoring at Home (BPM@h) initiative with free tools and guidance for EMIS and SystmOne. 

An important note about monitor cuff sizes:

Blood pressure monitors in the first round of BPM@h procurement have been issued with wide-range cuffs. Subsequent procurements may source monitors with wide-range, medium or large cuffs, or a combination.

Cuff (Code)Arm circumference range
Small (S) 17-22cm
Medium (M) 22-32cm [Standard/Normal cuff]
Large (L) 32-42cm
Wide-range (W) 22-42cm [i.e. ~ M+L]
Extra-large (XL) 42-50cm [Uncertain availability]

 

At-home Patient Group Identification tools (@hPGI)

Our @h-PGI tools for EMISWeb and SystmOne identify patients in Group 1, Group 2 and Group 3, as per the BPM@h Standard Operating Procedures. There are two versions of the tool:

SWX subdivides each of the defined groups into three subgroups:

  1. Subgroup S: BMI<18, i.e. patients potentially requiring a small/paediatric cuff.
  2. Subgroup W: BMI >=18 -- <38 (or no BMI recording), i.e. patients for whom a wide-range cuff is likely to be suitable.
  3. Subgroup X: BMI >=38, i.e. patients potentially requiring an XL cuff.

SMLX subdivides each of the defined groups into four subgroups:

  1. Subgroup S: BMI<18, i.e. patients potentially requiring a small/paediatric cuff.
  2. Subgroup M: BMI >=18 -- <28 (or no BMI recording), i.e. patients for whom a medium (standard) cuff is likely to be suitable.
  3. Subgroup L: BMI >=28 -- <38, i.e. patients likely to require a large cuff.
  4. Subgroup X: BMI >=38, i.e. patients potentially requiring an XL cuff.

We have published the SMLX version in case:

  • Current or future monitors are supplied with the medium cuff.
  • Practices plan to supply their own monitors and/or want to verify if patients using their own device have the correct cuff.

Please note: If only the SMLX version is available, Subgroup W can be created by merging SMLX subgroups M and L.

Download the @h-PGI tools and manuals:

 @h-PGI-SMLX@h-PGI-SWXManual
EmisWeb logo w50 variant @h-PGI-SMLX tool - EMIS [30KB] In preparation  BPM at Home - Manual [EMIS] v1.2 [PDF 486KB]
SystmOne Logo w50 variant @h-PGI-SMLX tool - SystmOne [2KB] @h-PGI-SWX tool - SystmOne [2KB]  BPM at Home - Manual [SystmOne] v1.0 [PDF 361KB]

Please note: These tools are intended to support practices participating in the national BPM@h Quality Improvement programme. Although every care has been taken to ensure the tools are accurate and fit for purpose, installation and implementation of @h-PGI is at the user's own risk. We are not able to offer 1:1 support for the tools but would welcome feedback, comments or corrections by email to ihse-ceg-admin@qmul.ac.uk - please include "@h-PGI" in the subject line.

Patient Groups

Patients with a diagnosis of hypertension (i.e. on the hypertension register, or with a valid and active hypertension code) can be issued a BPM@h monitor if they belong to Group 1 or Group 2 of the following (Group 3 patients should be encouraged to purchase their own monitor):

  • Group 1: Patients who are clinically extremely vulnerable (previously shielded population) with a last recorded blood pressure (BP) of systolic BP > 150mmHg and / or diastolic BP > 90mmHg and are not in group 2 
  • Group 2: Patients who are clinically extremely vulnerable who have had a prior stroke or transient ischaemic attack (TIA) and last recorded blood pressure of systolic BP > 150mmHg and / or diastolic BP > 90mmHg and do not already have a diagnosis of atrial fibrillation (AF)
  • Group 3: Patients whose last recorded blood pressure of systolic BP > 150mmHg and / or diastolic BP > 90mmHg and are not in groups 1 and 2

[Source: BPM@h Expert Advisory Group -- Standard Operating Procedure v1.1]

Notes:

  • Clinically Extremely Vulnerable (CEV) refers to their risk of serious complication from COVID19; CEV = Shielded population = SNOMED: High risk category for developing complication from coronavirus disease 19 caused by severe acute respiratory syndrome coronavirus 2 infection (SCTID: 1300561000000107)
  • Groups are derived from the adult population with an extant diagnosis of hypertension (i.e. on Hypertension register and/or with a QOF HYP_COD RefSet code)
  • Group 1 does not consider AF at all.  Any CEV patients with BP>150/90 and AF belong to group 1.

Monitors, Cuffs and BMI

Monitors

There are currently two models of monitors (both from Omron): the Omron M2 and the Omron M7.

The Omron M7 is preferred for patients in whom atrial fibrillation (AF) - a type of irregular heartbeat - is more likely but hasn't been diagnosed. For example, patients who have suffered a stroke or mini-stroke (TIA) which are both more likely in patients with AF. The Omron M7 can detect pulse anomalies characteristic of AF, hence its issue to Group 2 patients.

Cuffs

In patients with large arms (typically overweight but also physiologically large, e.g. body builders), the standard (medium) cuffs give an incorrect blood pressure reading. Such patients need larger cuffs. Similarly, underweight patients have smaller arm circumferences and need smaller cuffs. 

Estimating cuff requirements

Body Mass Index (BMI) and the Mid-Upper Arm Circumference (MUAC) correlate well (refs 1, 2, 3) and the MUAC is a fair estimate of cuff circumference requirements. The following graph illustrates this using data from ref 1:

Graph showing the relationship between MUAC and BMI and compatible cuffs

By using the linear equations in our references, standard cuff minimum and maximum lengths can be correlated to BMIs (via MUAC) as follows:

Table showing the relationships between cuff lengths, MUAC and BMI from the 3 keys references.Finally, using the above table (AVG column), we can relate cuff size to patient BMI and define appropriate BMI-based subgroups:

Table showing the relationships between cuff models and BMIs and the 2 derived subgroup schemes.

References

  1. Powell-Tuck, J., & Hennessy, E. M. (2003). A comparison of mid upper arm circumference, body mass index and weight loss as indices of undernutrition in acutely hospitalized patients. Clinical Nutrition (Edinburgh, Scotland), 22(3), 307–312. https://doi.org/10.1016/s0261-5614(03)00009-8
  2. Benítez Brito, N., Suárez Llanos, J. P., Fuentes Ferrer, M., Oliva García, J. G., Delgado Brito, I., Pereyra-García Castro, F., Caracena Castellanos, N., Acevedo Rodríguez, C. X., & Palacio Abizanda, E. (2016). Relationship between Mid-Upper Arm Circumference and Body Mass Index in Inpatients. PloS One, 11(8), e0160480. https://doi.org/10.1371/journal.pone.0160480
  3. Das, A., Saimala, G., Reddy, N., Mishra, P., Giri, R., Kumar, A., Raj, A., Kumar, G., Chaturvedi, S., Babu, S., Srikantiah, S., & Mahapatra, T. (2020). Mid-upper arm circumference as a substitute of the body mass index for assessment of nutritional status among adult and adolescent females: learning from an impoverished Indian state. Public Health, 179, 68–75. https://doi.org/10.1016/j.puhe.2019.09.010

© CEG Stuart Rison 2021

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