What Are Orthostatic Blood Pressures and Who Should Be Doing Them?

What are orthostatic blood pressures and why aren't doctors measuring them themselves? Orthostatic blood pressures are a measure of a person's blood pressure, preferably including the pulse, in the laying, sitting and standing position.  They are a decent but not perfect measure of intravascular volume status.  Orthostatic hypotension (ICD9 458.0) is a cause of syncope.   Syncope is  one of the top reasons I am asked to admit a patient to the hospital.  I find orthostatic blood pressure are almost never done before I am asked to admit a patient with syncope.  I do not know why.  Perhaps what we have is a difference in the culture of training between internal medicine and emergency medicine.   

Dr Centor started this discussion on orthostatic blood pressures over at his blog Medrants.  He thinks physicians  should measure orthostatic blood pressures for themselves. He is in the minority.  Check out his comments as well.  One ER doc in the comments suggests they are archaic and unhelpful.  I disagree.  When done correctly, a positive finding  is quite helpful and can often avoid admission to the hospital, potentially saving the Medicare National Bank tens of thousands of dollars in expensive and unnecessary radiographic and cardiovascular services.

With that said, I  don't think checking blood pressures should be a physician function anymore than drawing  blood or  bathing the patient is. These are nurse, nurse aide and laboratory  responsibilities. While orthostatic hypotension has a an ICD code, the actual performing of orthostatic blood pressures does not have a billable CPT® procedure code. However, the interpretation of the readings is paid for under routine E/M charges.  This is why you won't find many physicians taking their own readings.  They just don't have the time.  Orthostatic blood pressures have a specific technique that must be followed for accuracy.  The patient should be maintained in their supine, sit or stand position for three minutes before the readings are obtained. 

Having poorly done orthostatic blood pressures by the nurse or nurse aide does not mean physicians should take over the responsibility of doing them themselves.  It means the nurse or nurse aides should be trained to do them right.  We must maintain trust in the abilities of people around us if we are going to take care of patients together.  Stop treating nurses like robots.  That means they must also be trained to stop acting like robots as well. We are all professionals with unique and important training to fulfill highly skilled roles in patient care.  Let us act like it.  Nursing can  handle doing orthostatic blood pressures correctly, as they should. 

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