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Iatrogenesis IATROGENESIS Key Teaching Points For EM Faculty Addresses Cognitive & Behavioral Disorders & Emergent Intervention Modifications Competencies Primum Non Nocere ‐ “I Shall Do No Harm” Iatrogenesis: “Any unintended or Untoward consequence of well intended healthcare interventions.”2 Cascade iatrogenesis: “A series of adverse events triggered by an initial medical or nursing intervention initiating a cascade of decline.”2 Factors that predispose elderly patients to iatrogenesis 1. Senescent decline and decreased reserve in organ function. 4. Atypical presentation of disease 2. Multiple co‐morbitities and medications a. Absence of chest pain in ACS a. Drug‐Drug interactions b. Absent or less prominent fever in infectious processes b. Drug‐Disease interactions c. Adverse drug reaction as presenting symptoms (e.g., falls, dizziness, c. Multi organ system decompensation delirium, syncope) 3. Adverse environment of the ED d. Occult shock presenting with muted symptoms a. Unfamiliar surroundings 5. Potentially dangerous or high risk therapies b. High ambient noise level a. Anticoagulation in high fall risk patients c. Hallway as a treatment area b. Thrombolytic therapy for stroke in elderly > age 80 d. Insufficient analgesia c. Weigh risks versus benefits in frail older patients by balancing prognosis, preferences and underlying medically complexity. References 1. AMA Hippocratic Oath. Available from: http://www.imagerynet.com/hippo.ama.html. Accessed April 26, 2011 2. Francis DC. Iatrogenesis. New York (NY): Hartford Institute for Geriatric Nursing; 2005 Feb. Available from: http://consultgerirn.org/topics/iatrogenesis/want_to_know_more. Accessed June 22, 2011. 3. Kong TK. Journal of the Hong Kong Geriatrics Society 1997;8(1):1‐5. 4. Mobily PR, Skemp Kelley LS. J Gerontol Nurs 1991;17(9):5‐11. 5. Schroll M. Ugeskrift For laeger 1992:154(42):2889‐95. 6. Slzejf C, Farfal JM, Saporetti LA, et al. Einstein 2008;6(3):337‐342. 7. Wallace M, Fullmer T. Try This: Best Practices in Nursing Care to Older Adults 2007,1:1‐2. Available from: http://consultgerirn.org/uploads/File/trythis/try_this_1.pdf. Accessed June 22, 2011. 8. Webster JR Jr. Chicago (IL): Galter Health Sciences Library; 1999 Jun. Available from: http://www.galter.northwestern.edu/geriatrics/. Accessed June 22, 2011. Revised 9/20/11 Intervention in ED Potential Risks Recommendation UTI; Urethral injury caused by patient Use straight catheter specimen collection; Strict adherence to Foley catheter self‐ manipulating catheter to relieve proper indications for Foley; Chronic Foley should be changed discomfort every 30 days, even in ED Spinal immobilization w/ Move quickly to clear cervical spine; clinically by NEXUS Delirium; Agitation; pain in other long spine board & where appropriate or w/ x‐ray imaging & remove long spine areas; pressure ulcer risk cervical collar board & collar Bed rest Pressure ulcer risk Turn the patient every 2 hours, if long stay or boarding in ED Proper evidence‐based med selection w/ drug‐drug, drug‐ Falls; Delirium; over sedation leading to disease ADR’s kept in mind; Start low & go slow in dosing; Medications aspiration Avoid anticholinergic overtreatment; Avoid benzos in non‐ w/drawal states Hemorrhage; Pneumothorax; Arterial Avoid CVP when possible; Use ultrasound guidance Central line placement puncture & bleeding; Air embolism; techniques for placement whenever possible Infection Tethers, including IV lines; telemetry monitoring; Use tethers only when necessary; Bed rails up; Trendelenberg Posey restraints; pulse ox bed position, if tolerated clinically; Treat agitation w/ Delirium; Agitation; fall risk from finger monitors; Foley appropriate meds; Family @ bedside; Avoid hallway bed moving to foot of bed catheters; padded hand usage in these patients; Reduce vital sign checks during mittens; nasal cannulas; overnight boarding to floor frequency & policy automated BP cuffs Electrolyte imbalance; Weakness & Assess NPO status in ED every 6 hrs; Avoid orders for NPO NPO deconditioning; Dehydration w/ pre‐ status > 6 hours on general ED bridging orders renal azotemia .
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