St John Cymru-Wales

Blood Pressure Measurement

Standard Operating Procedure

Date Approved:

February 2015

Date Implemented:

February 2015

Date of Review:

February 2016

Version: 1.3

Document Control
Version:

1.3

Title:

Blood Pressure Measurement SOP

SOP Category:

Clinical / Operations

Date Approved:

February 2015

Date Implemented:

February 2015

Supersedes:

None

Date of Review:

February 2016

SOP Owner:

Healthcare Governance Committee

SOP Approval:

Healthcare Governance Committee

Supporting Documents

Document Name:

Medical Devices Policy

Infection Prevention Control Policy
Approved Equipment Guide
On Duty Guide

Version

Date

Author

Comment

1.0

November 2012

Paramedic Advisor

SOP Developed

1.1

January 2013

Paramedic Advisor

Change of Product

1.2

February 2014

Paramedic Advisor

Supplier Amendment

1.3

February 2015

Paramedic Advisor

Review Date change

of Supplier Information

Blood Pressure Standard Operating Procedure

Page 2

1. Introduction
St. John Cymru Wales (hereafter referred to as St John) acknowledges the benefit of
blood pressure (BP) measurement by approved, appropriately trained members to
diagnose and monitor a wide range of clinical conditions. St John is also aware of the
recent review into the reliability of the wide range of blood pressure devices and of the
potential Health and Safety and Patient Safety impacts of mercury-based blood
pressure devices, identified by the Medicines and Healthcare Regulatory Agency
(MHRA), and will seek to limit these through the use of robust policies and procedures.

2. Purpose
2.1.

St John requires that all parts of its activities and operations have an
understanding of their responsibilities for BP Measurement. The purpose of
this procedure is to:
a)
b)
c)
d)

ensure compliance with all relevant legislation

outline minimum training requirements for all personnel
identify specific responsibilities
provide all personnel with explicit guidance in the correct procedure for
obtaining a BP, and appropriate calibration and maintenance of the
equipment they hold in line with both Health & Safety and Control of
Infection requirements

3. Scope
3.1.

This procedure will apply to all personnel who have achieved the Enhanced
First Aider or Patient or Emergency Transport Attendant qualification. Due to
the potential for error and adverse events, BP monitoring will be restricted to
the aforementioned skill levels and a thorough training and assessment
package will be in place with annual recertification. Healthcare Professionals
(HCPs) are reminded that national clinical guidelines should be followed at all
times and that they are accountable to their own professional registering
body.

4. Responsibilities
4.1.

Healthcare Governance Committee

The Healthcare Governance Committee is responsible for the development of
this blood pressure measurement procedure and its review. It has overall
control over this document and is responsible for regularly updating it to
ensure this procedure reflects legislation and recognised best practice.
The Clinical Advisors will be responsible for promoting best practice in BP
measurement, including advice, support and guidance.

Blood Pressure Standard Operating Procedure

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Particular responsibilities include:

a) Reporting and investigating adverse incidents
b) Creating suitable training sessions which can be delivered to
personnel
c) Being available for clinical advice at all times of activity within St
John
d) Ensuring personnel are aware of their requirements under the
scope of this procedure
e) Being up-to-date on legislation pertaining to BP measurements
County Staff Officers / Line Managers
County Staff Officers / Line Managers hold delegated authority to carry out
inspections on behalf of the Healthcare Governance Committee; of all
members, including HCPs within St John.
Particular responsibilities include:
a) Reporting adverse incidents involving BP measurements so that these
can be investigated in a timely manner
b) Ensuring that this procedure is followed and BP monitoring is only carried
out by approved personnel who hold the following qualifications:

Enhanced First Aider (EFA),

Patient Transport Attendant (PTA)

Emergency Transport Attendant (ETA)

Healthcare Professional (HCP).

c) Ensuring correct implementation and development of the approved training

package
d) Ensuring that personal protection and basic hygiene precautions are
adhered to
e) Ensuring risk assessments are in place
f) Keeping accurate records to assist in the preparation of reports to the
Healthcare Governance Committee.

Blood Pressure Standard Operating Procedure

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All personnel
All personnel (including volunteers and employees) have the following
responsibilities under this procedure:
a) Making themselves familiar with this procedure
b) Adhering to and observing the requirements of this Standard Operating
Procedure, ensuring they have been approved to undertake this extended
role
c) Participating in BP measurement training and attend / complete updates
as change in procedure or equipment dictates
d) Reporting dangerous or untoward incidents and situations as soon as they
are identified, take action to prevent others being affected and assist with
any resulting investigation.
e) Ensuring that only approved and correctly maintained equipment is used.
f) Ensuring personnel know what action to take should equipment become
damaged, contaminated, or produces erroneous results.
g) Wearing protective clothing and equipment in accordance with relevant
working procedures applicable to the task being undertaken, ensuring that
sharps waste is disposed of safely and in line with national and local
guidance
h) Observing personal protection and basic hygiene precautions

5. Indications for Blood Pressure Measurement

5.1.

Blood pressure measurement gives an indication of the bodys cardiac output

and any resistance met when the blood is expelled from the heart through the
blood vessels. Within the scope of St John practice, its primary function would
be in the monitoring of patients; however it also has a place in the
management of any acutely unwell patient.

5.2.

To ensure continuity of care and to prevent adverse incidents, all BP results

are displayed and interpreted in mmHg ONLY. This is current best practice in
the United Kingdom for healthcare organisations.

Blood Pressure Standard Operating Procedure

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6.

Blood Pressure Measurement Equipment

6.1.

The information below highlights the Blood Pressure Monitoring Equipment for
use by St John personnel. No personal devices are to be used at any time. All
of the equipment listed is required.
a) Approved Blood Pressure Device:
Model :

Sapphire Sphygmomanometer

Supplier:

St John Wales Supplies

Notes:

b) Approved Stethoscope:
Model :

Sprague Rappaport Stethoscope

Supplier:

St John Wales Supplies

Notes:

6.2.

The MHRA conducted a study in 2006 and established a committee on Blood

Pressure Monitoring in Clinical Practice; following concerns regarding the use
of mercury based sphygmomanometers. These concerns were based around
environmental and health and safety issues. The committee concluded that if
utilised, recommendations are made for mercury spillage kits to be available
(Recommendation 1, MHRA, 2005).

6.3.

With this recommendation in mind, coupled with potential cost implications; St

John will prohibit the use of mercury sphygmomanometers and therefore only
aneroid sphygmomanometers and automatic cycling non-invasive blood
pressure (NIBP) monitors will be used on approved devices.

6.4.

Manual Blood Pressure Devices

When undertaking manual blood pressure measurements, there may be
differences between the auditory acuity of personnel and digit preference is a
common occurrence; particularly with personnel recording a disproportionate
number of readings ending in five or zero (MHRA, 2006).
To minimise this risk, formal blood pressure training will be undertaken and
personnel instructed that additional information about the patient must be

Blood Pressure Standard Operating Procedure

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obtained; such as the regularity and strength of the pulse, skin condition and
any tremors.
6.5.

Automated Blood Pressure Devices

Personnel should be aware that for patients suffering muscle tremors,
abnormal heart rhythms, weak pulse or very low blood pressure due to shock
some automated blood pressure devices may fail to obtain a reading and
will either indicate an error code or give unreliable results.
Some automated non-invasive blood pressure devices may produce different
readings to those by manual devices due to the configuration of the devices.
Only approved automatic blood pressure devices are permitted within St
John. Details are available in the Approved Equipment Guide.

6.6.

Cuff Size
Incorrect cuff size is a major source of error for both manual and automated
devices. An under-sized cuff tends to over-estimate blood pressure, while an
over-sized cuff may under-estimate (MHRA, 2006).
Incorrect cuff placement can also be a contributing factor. A range of blood
pressure cuff sizes should be made available. Cuffs should also be regularly
inspected for damage and replaced as required.

6.7.

Supply & Purchase

Only approved blood pressure devices that are CE marked to show
compliance with the Medical Devices Policy and included in the Approved
Equipment Guide should be used.

6.8.

Manual Defibrillators / AEDs with BP Monitoring Capability

Manual defibrillators or AEDs with manual override shall only be used by
Healthcare Professionals who regularly operate manual defibrillators in their
clinical practice.
Non-Healthcare Professionals are prohibited to use this equipment or any
functions within it unless under the direct supervision of a Healthcare
Professional.

7. Blood Pressure Measurement Equipment Procedure

7.1.

After ensuring the blood pressure machine has been appropriately calibrated,
the following procedure is carried out
1. Explain and ask the patient for their consent to carry out the procedure

Blood Pressure Standard Operating Procedure

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2. Adopt appropriate Infection Control methods

3. Ensure that the patients arm is free of restrictive clothing
4. Apply the cuff around the arm firmly with the bladder centered over the
brachial artery
5. Advise the patient that the cuff will temporarily tighten
6. Palpate the radial artery whilst inflating the cuff until the pulse is no longer
palpable. Note pressure and deflate the cuff rapidly
7. Position stethoscope over the brachial artery and inflate cuff to predetermined pressure
8. Deflate the cuff at a suitable rate and note the pressure when the first two
consecutive heart beats are heard = Systolic Pressure
9. Continue to deflate the cuff and note the pressure when the heart beat can
no longer be heard = Diastolic Pressure
10. Remove the cuff from the patients arm
11. Equipment cleaned and prepared for next patient
12. Remove gloves and wash hands
Please note that patients must receive a manual blood pressure (using a
sphygmomanometer) if automatic blood pressures provide abnormal readings.

8. Calibrating blood pressure equipment

8.1.

All blood pressure equipment should be calibrated at least every six months
or if the integrity or reliability is questioned when the result is not in keeping
with the clinical condition of the patient.

8.2.

For the procedure of calibrating the blood pressure devices, refer to the
manufacturers guideline.

9. Training
9.1.

MHRA, 2005 (Recommendation 7), states that the method of auscultation as

a way of determining blood pressure should continue to be taught. Due to this,
the skill of auscultation is incorporated in the BP measurement training by St
John (see section 8.1).

9.2.

All personnel undertaking the EFA, PTA or ETA course will receive training on
how to correctly carry out the blood pressure measurement procedure. All

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personnel already holding this qualification will receive an additional,

mandatory training course.
9.3.

Monitored training will take place in the form of formative assessments and
completion of the OSCE Record Sheet (Appendix I).

9.4.

Assessments will take place in the form of an Objective Structured Clinical

Examination (OSCE) with a Skills Test 25A (assessment criteria) undertaken
by an NHS Paramedic or IHCD Technician.

9.5.

It is a requirement that all personnel undergo an OSCE on an annual basis to

ensure the required standards are still being met.

9.6.

Assessment and Management of patients undergoing a blood pressure

measurement will be used in conjunction with the National Institute for Health
and Clinical Excellence (NICE) Hypertension Guidelines, Blood Pressure
Association Guidelines and those contained within the Joint Royal Colleges
Ambulance Liaison Committee (JRCALC) UK Ambulance Service; Clinical
Guidelines.

10. Reporting incidents, injuries and accidents

10.1. All personnel should be aware that there is a potential for error with BP
measurement and they should familiarise themselves with the training
materials and practice the skill regularly.
10.2. All potential and actual adverse incidents concerning BP measurements as a
result of device malfunction should result in the device being withdrawn from
service, pending investigation. Personnel should be mindful that their first
priority should be the care of their patients; BP measurements should not
delay patients being removed to an Emergency Department for further
management if required.
10.3. Any incident involving BP measurement devices or skills should be reported
immediately to a member of County Staff.
10.4. In addition to the above procedure, an Adverse Incident / AC 3 Form must be
completed and if applicable, a RIDDOR notification may need to be completed
at the earliest opportunity and submitted without delay.

11. Monitoring of Compliance

11.1. This procedure will be monitored by the Healthcare Governance Committee
and updated accordingly.
11.2. Compliance to this procedure will be regularly checked through local audits
including PRF audits and monitoring.

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11.3. Reported breaches of this procedure will be discussed with those concerned
and maybe dealt with under other polices, regulations or legislation.

12. References
Blood Pressure Measurement (2006), Medical Device Bulletin, Medicine and
Healthcare Regulatory Agency, London
National Institute for Clinical Excellence (2011) Hypertension, Clinical Management
of Primary Hypertension in Adults, National Institute for Clinical Excellence, London
Report of the Independent Advisory Group on Blood Pressure Monitoring in Clinical
Practice (2005) Medicine and Healthcare Regulatory Agency, London

Blood Pressure Standard Operating Procedure

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Appendix I

Blood Glucose & Blood Pressure Measurement

Objective Structured Clinical Examination (OSCE)
To prepare you for the final OSCE assessment in Blood Pressure and Blood Glucose Measurement, please ensure that you
allow ample time to practice these skills. Your trainer must witness measurements and complete all elements below prior to
your final assessment. It is not necessary to take blood samples for Blood Glucose during each practice. It is acceptable for
this to be demonstrated in the initial practice and final assessment, with simulation during other attempts.
Blood Pressure Measurement
Procedure

Trainer Initial
1

Blood Glucose Measurement

Procedure

1. Explain and ask the patient for

their consent to carry out the
procedure
2. Adopt appropriate Infection
Control methods

1. Explain and ask the patient for

their consent to carry out the
procedure
2. Adopt appropriate Infection
Control methods

3. Ensure that the patients arm is

free of restrictive clothing

3. Prepare equipment and ensure

the glucose monitor is fully
calibrated

4. Apply the cuff around the arm

firmly with the bladder centred
over the brachial artery

4. Clean the tip of the selected

finger with wipe and allow to dry

5. Advise the patient that the cuff will

temporarily tighten

5. Prepare the test strip, ensuring

that it is still in date and load
into glucose monitor

6. Palpate the radial artery whilst

inflating the cuff until the pulse is
no longer palpable. Note pressure
and deflate the cuff rapidly

6. Prick the side of the finger with

the lancet and squeeze the
finger to draw blood

7. Position stethoscope over the

brachial artery and inflate cuff to
pre-determined pressure

7. Dispose of the lancet into a

Sharps Box

8. Deflate the cuff at a suitable rate

and note the pressure when the
first two consecutive heart beats
are heard = Systolic Pressure
9. Continue to deflate the cuff and
note the pressure when the heart
beat can no longer be heard
= Diastolic Pressure
10. Remove the cuff from the patients
arm

8. Place the drop of blood onto the

test strip so that the strip is
covered
9. Give the patient a gauze swab
and advise them to apply
pressure to stop bleeding
10. Record the reading from the
glucose monitor display

11. Equipment cleaned and prepared

for next patient

11. Dispose of the test strip into a

clinical waste bag

12. Blood Pressure Reading

diagnosed as Normal or
Hyper/Hypotension correctly

12. Blood Glucose Reading

diagnosed as Normal or
Hyper/Hypoglycaemia correctly

Blood Pressure Standard Operating Procedure

Trainer Initial

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