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Original article

Ambulatory blood pressure monitoring in children during the COVID-19 pandemic

Woroniecki, Robert P.a,b; Flynn, Joseph T.c,d

Author Information
Blood Pressure Monitoring: May 02, 2022 - Volume - Issue - 10.1097/MBP.0000000000000603
doi: 10.1097/MBP.0000000000000603

Abstract

Introduction

COVID-19 is the severe acute respiratory illness caused by the novel coronavirus (SARS-CoV-2) first detected in Wuhan, China, in December of 2019 that spread rapidly across the globe, prompting the WHO to declare a pandemic on 11 March 2020 [https://www.who.int/emergencies/diseases/novel-coronavirus-2019]. Although this virus spreads from person to person via respiratory secretions and aerosols, it was widely reported that at room temperature, SARS-CoV-2 is stable on environmental surfaces and may remain viable up to 7 days [1]. The novelty of the virus, its speed of transmission, and rising death toll lead to widespread lockdowns in several countries, including the USA. These lockdowns had profound impacts on healthcare delivery, including cancelation of routine surgeries, closures of outpatient clinics, widespread switch to telehealth [2], etc.

In this pandemic environment, questions arose regarding hypertension (HTN) management in children, including adherence to published guidelines. Specifically, the ability to continue widespread use of ambulatory blood pressure monitoring (ABPM) as recommended in the recent American Academy of Pediatrics Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents [3] seemed likely to be hampered by the pandemic.

To better understand how COVID-19 impacted HTN care and utilization of ABPM in particular, we undertook an Internet survey of pediatric nephrologists and pediatric hypertension centers in North America We hypothesized that the reduction in in-person patient–physician visits and the potential for transmitting SARS-CoV-2 through contaminated medical equipment would lead to a significant reduction in provision of ABPM as recommended by current guidelines.

Methods

We distributed a survey consisting of 10 questions about the current practices of practitioners and pediatric HTN Centers with respect to ABPM use, equipment cleaning, and overall HTN management (Appendix I), supplemental digital content 1, https://links.lww.com/BPMJ/A163, on a web-based survey platform (SurveyMonkey; https://www.surveymonkey.com) and distributed the link through e-mail to individual participants listed in the members only section of the Pediatric Nephrology Research Consortium (PNRC; https://pnrconsortium.org/). The PNRC was initially called the Midwest Pediatric Nephrology Consortium when it was established in 2004 and now includes 125 sites across North America, making it broadly representative of practicing North American Pediatric Nephrologists (https://pnrconsortium.org/about/history). We collected responses between 14 April 2020 and 30 June 2020. Responses were collected through the SurveyMonkey web platform.

Statistics

We used descriptive statistics and tabulations with assistance of SurveyMonkey and Microsoft Excel software (Microsoft, Inc., Redmond, Washington, USA).

Results

We received 81 responses from 323 individuals surveyed (25.1% response rate) and from 54 out of 80 pediatric nephrology centers (67% response rate) across the USA, Canada, and Germany (Appendix II), supplemental digital content 1, https://links.lww.com/BPMJ/A163. Survey participants consisted of three (3.9%) instructors, 35 (44.9%) assistant professors, 20 (25.6%) associate professors, and 20 (25.6%) professors, and three (3.9%) did not identify their academic rank. The majority of responding pediatric nephrologists [45/74 (60.8%)] at PRNC centers do not have dedicated HTN clinics, and most [45/78 (57.7%)] have less than 10 monitors available for their patient use (Table 1).

Table 1 - Number of functional ambulatory blood pressure monitoring devices available in your unit
Number of devices Responses, n (%)
1–5 22 (28.2)
6–10 23 (29.5)
11–15 8 (10.3)
16–20 11 (14.1)
≥21 12 (15.4)
Do not know 2 (2.6)
Total 78 (100)

During the pandemic, most providers (46/81 or 56.8%) continued to provide ABPM to their patients, but only 17 of 81 (21%) used disposable cuffs, and only 23 (28.4%) had specific equipment cleaning protocols in place. In 69.1% of cases, equipment was cleaned by registered or license practical nurse, 2.5% by physician or nurse practitioner, and only 12.3% by hospital/technician/administrator. Almost 5% of providers did not know who in their center is responsible for cleaning the ABPM equipment. Those results are summarized in Table 2. Notably, a relatively small minority of respondents felt comfortable (21/81, 26.2%) or very comfortable (9, 11.2%) in following published guidelines on ABPM during the pandemic, and 18 (22.5%) felt uncomfortable, or 6 (7.5%) very uncomfortable. Finally, only half of practitioners felt comfortable with managing HTN via telehealth (Fig. 1).

Table 2 - Tabulated answers to 10 questions of ambulatory blood pressure monitoring in children during the COVID-19 pandemic survey
Question content Responses (%)
1 What is your institution name and do you have a dedicated pediatric hypertension center? Institution name; See appendix II
Yes 47.5%
No 52.5%
2 What is your academic rank? Instructor 7.9%
Assistant Professor 47.4%
Associate Professor 15.8%
Professor 28.9%
3 How many functional ABPM units does the center have? See Table 1.
4 Is your ABPM program/division continuing to provide services thru COVID-19 pandemic? Yes 75%
No 25%
5 Do you use disposable cuffs? Yes 17.5%
No 70%
Do not know 12.5%
6 Are you aware of ABPM supplier guidance on cleaning of the equipment during influenza season? Yes 50%
No 27.5%
Do not know 22.5%
7 Who in your center is responsible for cleaning the equipment? Physician/NP 2.5%
Nurse/LPN 67.5%
Technician 5%
Hospital/office administrator 7.5%
Do not know 5%
Other 12.5%
8 Do you have special protocols in place to check on the cleaning procedures? Yes 27.5%
No 45%
Do not know 27.5%
9 What is your comfort level in following published guidance on ABPM use in children during a pandemic?a Very uncomfortable 5%
Uncomfortable 17.5%
Neutral 35%
Comfortable 30%
Very comfortable 12.5%
10 What is your comfort level in managing children with hypertension via telehealth (two-way secure video/audio)?a Very uncomfortable 0%
Uncomfortable 32.5%
Neutral 20%
Comfortable 40%
Very comfortable 7.5%
ABPM, ambulatory blood pressure monitoring; LPN, Licensed Practical Nurse; NP, Nurse Practitioner.
aResponders provided additional comments presented in Supplementary Table, supplemental digital content 2, https://links.lww.com/BPMJ/A164.

F1
Fig. 1:
Practitioners comfort level in managing children with HTN via telehealth (two-way secure video/audio). HTN, hypertension.

In addition, several responders provided fee-text comments regarding their institutional policies and comfort level, which are listed in Supplemental Table 1, supplemental digital content 2, https://links.lww.com/BPMJ/A164. Given the small number and anecdotal nature of the free-text responses received, we have added a new Table 3 that gives additional details on how these comments were assessed.

Table 3 - Qualitative analysis of responders’ comments
Comments for question about comfort level in following published guidance on ABPM during pandemic
Comments submitted, n = 9
 Unaware of guidance, n = 2
 Reasons for change in practice, n = 7
 Mailing ABPM instead of in-person placement, n = 1
 Holding off ABPM due to staff furloughs, n = 1
 Holding off ABPM due to hospital policy, n = 5
Comments for question about comfort level in managing children with HTN via telehealth
Comments submitted, n = 15
 Lack of reliability of home/TVP BP measurements, n = 6
 Lack of home BP equipment, n = 6
 Comfortable with teens or established patients, n = 6
 Other, n = 6
ABPM, ambulatory blood pressure monitoring; BP, blood pressure; HTN, hypertension.

Discussion

This survey revealed that managing pediatric HTN, specifically the continued use of ABPM, proved challenging during the COVID-19 pandemic. It is a striking finding that over 40% of pediatric nephrology practitioners did not actually provide ABPM to their patients and that the majority had no protocols in place for cleaning of the equipment. Moreover, a significant percentage were not comfortable with adhering to published guidance or with providing HTN care via telehealth. These data underscore the need to develop guidance for continuing routine HTN care and adherence to consensus recommendations during healthcare crises.

Even though severe and symptomatic COVID-19 requiring hospitalizations affected a disproportionally older patient population, pediatric services in the USA and elsewhere experienced patient volume reductions during widespread lock downs [4]. This may explain in part the drastic reductions in HTN services provided to children during that time. In addition to reductions in outpatient services, health systems were dealing with shortages of personal protective equipment [5], which likely further limited provision of routine care such as ABPM.

A lack of reliable information on the best methods of cleaning ABPM devices could partly explain our findings. At the time of our survey, one manufacturer of widely used ABPM equipment (Spacelabs Healthcare, Snoqualmie, Washington, USA) did not have any specific information on disinfection protocols that addressed the unique aspects of the SARS-CoV-2 coronavirus (https://www.spacelabshealthcare.com/support/cleaning-instructions/). Subsequently, Spacelabs Healthcare has added extensive cleaning instructions to its website at https://www.spacelabshealthcare.com/support/cleaning-instructions/. In addition, in March 2020, there was widespread national shortage of Clorox Healthcare Bleach Wipes and PDI Sani-Cloth Bleach Wipes and similar products registered with the EPA during 2018 as effective against Mycobacterium tuberculosis, Norovirus, C. difficile spores, and other pathogens. These shortages were predicted to continue well into 2021 [5,6] creating ongoing impacts on protocols for disinfecting ABPM equipment between patients.

As previously mentioned [2], the onset of the COVID-19 pandemic saw rapid increases in the use of telehealth services, requiring learning about new technologies by both patients and providers. While there are potential benefits of telehealth services such as convenience and potential increased access to care, issues such as reimbursement, staff familiarity with telemedicine equipment, and documentation concerns are potential barriers [7]. With respect to HTN care, while devices for remote blood pressure (BP) monitoring are commercially available and their usage has been recommended by consensus bodies [8–10], the availability of such equipment in the early stages of the pandemic was likely limited, meaning that most pediatric nephrologists would be unfamiliar with HTN care by telehealth. A further barrier to widespread use of telemedicine in pediatric HTN care is the paucity of home BP devices validated in the pediatric population [11], which would limit the ability of families to monitor their children’s BP at home and communicate those results to their physicians. Other barriers to more widespread use of home BP monitoring in pediatrics include a lack of normative data on home BP values [3] and lack of insurance coverage of durable medical equipment, especially by public programs such as Medicaid, which cover a much larger share of children than adults [12].

One potential limitation of our study is the relatively low individual response rate. However, we collected information from most centers in the PNRC, and it is unlikely that the impact of the pandemic practices on HTN management in children would have varied significantly from practitioner to practitioner in the same center. Additionally, our survey was limited to pediatric nephrologists who are members of the PNRC and so may not be applicable in other settings. Practice patterns in pediatrics are notably different from those in adult medicine. Given the high frequency of kidney disease as a cause of HTN in childhood, pediatricians and pediatric cardiologists typically refer pediatric HTN patients for evaluation and treatment to pediatric nephrologists. Pediatric cardiologists focus on diagnostic imaging and treatment of congenital heart disease and structural heart anomalies. Therefore, it is important to capture pediatric nephrologists’ responses regarding ABPM and pediatric HTN management. Therefore, we feel that our findings provide valuable insight into how a healthcare crisis can affect management of a common condition such as childhood HTN.

Finally, although we are not able to calculate and provide data on the numeric difference between ABPM studies performed before and after the COVID pandemic at the responding centers, our data would suggest that use of ABPM likely decreased. Especially during the early stages of the pandemic, its use would have been limited because many centers operated remotely or closed altogether. In addition, since the mode of viral transmission was not exactly known early on, this created an issue of equipment handling and cleaning that restricted use of ABPM, as noted in our survey respondents’ comments.

Conclusion

In summary, our survey identified a knowledge gap between official guidance and practical situations practitioners and patients faced during the pandemic. Our patient–physician communication during this pandemic relied heavily on technology like WiFi, internet access, etc. Some responders indicated that families who can afford BP monitor at home could be monitored and managed through telehealth. This underscores the need for high-quality affordable equipment to be made available to families who could not otherwise afford it. The responses of PNRC’s nephrologists may indicate the need for thorough health care system preparation for the next wave of this or future pandemics and other emergencies we may face. Our findings underscore the need to supplement existing and future guidance on how to manage HTN centers, HTN patients, and equipment during healthcare crises. Resilience of our healthcare system is an important factor supporting resilience of individual providers and enhancing the care that they deliver to their patients. We must pay attention to new guidance, research, and development in pediatric HTN and to our equipment and infrastructure that could keep communication and flow of information open during future national emergencies.

Acknowledgements

Ethics statement: all participants provided written informed consent before participating in the study. The study was approved by the Institutional Review Board at Stony Brook University Hospital. The study was also reviewed and approved by the PNRC Executive Committee.

Conflicts of interest

There are no conflicts of interest.

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    Keywords:

    COVID-19; equipment cleaning; hypertension guidelines; pediatric; telehealth

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