More than 145 million emergency department (ED) visits take place each year in the United States (U.S.), and the estimated prevalence of elevated blood pressure (BP) among these patients is close to 45 % [1], [2]. Nearly half of patients with elevated BP are asymptomatic and are in the ED for reasons unrelated to BP [3], [4], [5], [6]. ED providers encounter patients with severely elevated BP daily, and yet adherence to minimal standards of BP reassessment and referral to outpatient medical care, as recommended by the American College of Emergency Physicians (ACEP), is limited [7], [8], [9], [10]. Implementing targeted interventions can reduce the burden of hypertension and its complications and help to eliminate the disparities in hypertension outcomes. The 2013 ACEP Clinical Policy recommends referral to a Primary Care Provider (PCP) for hypertension management for two BP readings ≥ 140/90 mmHg found during the ED visit in patients who are asymptomatic, preferably within 2-weeks (this BP level is defined as Stage 2 hypertension) [10], [11]. However, the ACEP policy is inconsistently adhered to by physicians and nurses, with referral rates as low as 5 % [10]. Furthermore, the ACEP policy does not account for the impact of social determinants of health (e.g., access to primary care, resources to obtain prescriptions, etc.) on patients' ability to follow through with referrals, which may further exacerbate health disparities [12], [13], [14].

Elevated BP found during the ED visit is a compelling and powerful predictor for the presence of chronic hypertension [15], [16], [17]. However, the management of hypertension in the ED shows significant variability. Souffront et al. found that the heterogeneity observed in managing asymptomatic hypertension in the ED can be attributed to multiple factors [7], [8], [9]. These include a lack of awareness of the ACEP policy, insufficient resources, and attitudinal barriers such as clinical inertia. Compounding this issue are false beliefs surrounding asymptomatic hypertension in the ED. One major issue is the belief that ED high BP is caused by pain, anxiety, or other stressors, raising questions about the predictive value of BP readings and whether hypertension screening based on routine recordings in the ED is useful. In this regard, multiple investigations have found no conclusive evidence linking ED hypertension to pain or anxiety, indicating that such an explanation is an oversimplification that could potentially endanger the patient [14,15],[18]. The consequences of poor management of asymptomatic hypertension in the ED include increased risk of an adverse cardiovascular event (myocardial infarction, stroke, or incident atherosclerotic CVD) with a hazard ratio of 2.09 (95 % CI 1.67–2.60) for those with BP ≥ 140/90 mmHg at time of ED visit, and an odds ratio of 3.12 (95 % CI 2.44–3.99) for those with BP ≥ 160/100 mmHg at the time of ED visit, compared to patients with BP ≥ 140/90 mmHg, within 3.5 years [15]. As many as 100 % of patients in the ED are found to have subclinical heart disease, as a result of chronic uncontrolled hypertension [13,[19], [20], [21], highlighting the need for early identification, timely intervention, and nurse-led strategies to prevent adverse sequelae.

While nurse-led interventions have proven effective in improving systolic BP and BP control, none have been specifically designed for the ED setting [22]. Similarly, ED-based telehealth interventions for hypertension management are scarce, yet they show promise [12,23]. However, no existing models are nurse-led. To address this gap, we developed the Telehealth Referral to Improve Outcomes (TRIO) intervention, leveraging the expertise and trust of nursing and to improve the delivery of care for ED patients with asymptomatic hypertension. The TRIO intervention identifies asymptomatic hypertensive patients during ED discharge and assigns them a registered nurse who contacts them post-discharge to connect them to a primary care provider (PCP). In this paper, we present findings from our pilot study, which is the first step prior to implementing a larger trial. The study's main objective was to assess the feasibility and acceptability of the TRIO intervention, focusing on recruitment productivity, retention, and attrition rates.