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Emergency Physician Recognition of Adverse Drug-Related Events in Elder Patients Presenting to an Emergency Department

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Emergency Physician Recognition of Adverse Drug-Related Events in Elder Patients Presenting to an Emergency Department ACAD EMERG MED d March 2005, Vol. 12, No. 3 d www.aemj.org 197 Emergency Physician Recognition of Adverse Drug-related Events in Elder Patients Presenting to an Emergency Department Corinne Miche` le Hohl, MD, CCFP, FRCPC, Caroline Robitaille, BPharm, MSc, Vicky Lord, BPharm, MSc, Jerrald Dankoff, MD, CSPQ, Antoinette Colacone, BSc, CCRA, Luc Pham, BSc, Anick Be´ rard, PhD, Jocelyne Pe´ pin,BPharm,MSc,MarcAfilalo,MD,FRCPC Abstract Objectives: The authors examined the ability of emergency ADREs that were not associated with the chief complaint physicians (EPs) to recognize adverse drug-related events (32.1%; 95% CI = 14.8% to 49%). EPs recognized six of seven (ADREs) in elder patients presenting to the emergency severe ADREs (85.7%), 13 of 23 moderate ADREs (56.5%; department (ED). Methods: This was a prospective obser- 95% CI = 36.8% to 77%), and none of the mild ADREs. vational study of patients at least 65 years of age who Recognition of ADREs varied with medication class. presented to the ED. ADREs were identified using a vali- Conclusions: EP performance was superior at identifying dated, standardized scoring system. EP recognition of severe ADREs relating to the patients’ chief complaints. ADREs was assessed through physician interview and However, EP performance was suboptimal with respect to subsequent chart review. Results: A total of 161 patients identifying ADREs of lower severity, having missed a signif- were enrolled in the study. Thirty-seven ADREs were icant number of ADREs of moderate severity as well as ones identified, which occurred in 26 patients (16.2%; 95% unrelated to the patients’ chief complaints. ADRE detection confidence interval [CI] = 10.5% to 22.0%). The treating methods need to be developed for the ED to aid EPs in EPs recognized 51.2% (95% CI = 35.2% to 67.4%) of all detecting those ADREs that are most likely to be missed. ADREs. There was better recognition of those ADREs Key words: emergency department; adverse drug-related related to the patient’s chief complaint (91%; 95% events; drug-related morbidity; physician performance. CI = 74.1% to 100%) as compared with recognition of ACADEMIC EMERGENCY MEDICINE 2005; 12:197–205. Adverse drug-related events (ADREs) are unfavorable From the Royal College Emergency Medicine Training Program, medical events related to the use and misuse of over- McGill University (CMH), Montreal, Quebec, Canada; Faculty of Pharmacy, University of Montreal (CR, VL, AB), Montreal, Quebec, the-counter and prescription medications. ADREs have Canada; Emergency Department, Sir Mortimer B. Davis Jewish emerged as important health risks, especially in elders, General Hospital, McGill University (JD, AC, MA), Montreal, who tend to consume the most medications. ADREs Quebec, Canada; Department of Medicine, McGill University (LP), may account for up to 28% of emergency department Montreal, Quebec, Canada; and Department of Pharmacy, Sir (ED) visits1–3 and 30% of hospital admissions4–6 and Mortimer B. Davis Jewish General Hospital, McGill University (JP), Montreal, Quebec, Canada. significantly inflate hospital expenditures. In 1998, Received January 27, 2004; revision received July 22, 2004; accepted ADREs were identified as the sixth leading cause of August 10, 2004. in-hospital mortality in the United States.7,8 Presented at the Association des Me´decins d’Urgence du Que´bec In an attempt to reduce drug-related morbidity and scientific meeting, Quebec City, Quebec, Canada, November 2003. mortality, researchers have begun to study clinicians’ Supported by contributions from Programme MSSS - Re´gies re´gion- ales—FRSQ de soutien a` la recherche sur la proble´matique des ability to detect and treat ADREs. Large-scale studies urgences, AMUQ Residency Research Bursary, the Brownstein have shown that clinicians taking care of inpatients Emergency Department Research Endowment Fund and the Armand detect only 5%–15% of drug-related events in hospitals Afilalo and Family Emergency Department Research Endowment Fund. without systematic surveillance systems.9,10 In con- Dr. Be´rard is a research scholar from the Canadian Health Foundation trast, reports from intensive care settings indicate that and the Canadian Institutes of Health Research (Rx&D/CHIR). Address for correspondence: Dr. Corinne Hohl, MD, FRCP, Emer- the presence of a pharmacist on rounds decreases the gency Department, Vancouver General Hospital, 885 West 12th Ave, rate of preventable ADREs by helping intercept errors Vancouver, British Columbia, Canada. Fax: 604-875-4872; e-mail: as well as unrecognized events.11 These studies have [email protected]. Address for reprints: Marc Afilalo, MD, served as the basis for justifying the cost of a pharmacist FRCPC, Emergency Department, Sir Mortimer B. Davis Jewish present on intensive care unit and medical ward rounds General Hospital, 3755, Coˆte Ste-Catherine Road, Office D012, Montreal, Quebec, H3T 1E2, Canada. Fax: 514-340-7519; e-mail: in many institutions. marc.afi[email protected]. The few published studies that have documented the doi:10.1197/j.aem.2004.08.056 significance of ADREs in the ED setting1–3,12 have not 198 Hohl et al. d RECOGNITION OF ADVERSE DRUG-RELATED EVENTS assessed the performance of emergency physicians All EPs were informed of the study by e-mail and (EPs) in recognizing such events. This is important flyers before the beginning of the study period. All because most EDs are not equipped with systematic EPs working at the SMBD-JGH during the study ADRE surveillance systems and do not have the period who were not directly involved in the study funding available for a pharmacist to be on call 24 protocol or the ADRE evaluations were included. hours a day/7 days a week for the purpose of screening Once a patient had been enrolled in the study, high-risk patients. Given the frequency of ADREs in a pharmacy resident collected data using standard- the ED, it is critical to understand EP performance ized data collection forms. The pharmacy residents in detecting ADREs in order to improve quality of care collected data on demographics, ED chief complaint, and, if necessary, develop and implement ADRE other patient complaints, medical history, known screening tools to help EPs in this difficult task. allergies and medication intolerances, and medication The objectives of this study were to examine EP history including supplements, over-the-counter performance in recognizing ADREs in elder patients medications, and herbal remedies. Physical examina- who present to our ED and to characterize the events tion findings, laboratory test information, diagnostic that went unrecognized. test results, ED or admission prescriptions, and ad- mission and discharge diagnoses were collected as well. The pharmacy residents reviewed each medica- METHODS tion history over the telephone with the patient’s Study Design. A prospective observational study community pharmacist(s) for accuracy and complete- was conducted on a convenience sample of elder pa- ness. The research team did not intervene in patient tients presenting to the ED at Sir Mortimer B. Davis care until after the ADRE evaluation and EP interview Jewish General Hospital (SMBD-JGH). The study were completed. The research team did not order any protocol was reviewed and approved by our hospi- laboratory tests. tal’s institutional review board. Informed written consent was obtained from all subjects. Definitions and Identification of ADREs. For study purposes, ADREs were defined as ‘‘any unfavorable medical event related to medication use or misuse.’’1 Study Setting and Population. The SMBD-JGH is This definition comprises adverse drug reactions, a 637-bed adult university teaching hospital in Mon- adverse drug interactions, drug withdrawal reactions, treal, Quebec, Canada, with an annual ED census of and adverse events arising from prescription errors 60,000 patients. It serves as an urban university and noncompliance.1 Adverse drug reactions were teaching hospital as well as a community hospital defined according to the World Health Organization for the surrounding neighborhood. as ‘‘noxious and/or unintended responses to medica- Patients older than 65 years of age who were tion which occur despite appropriate drug dosage for present in the SMBD-JGH ED between January 3, prophylaxis, diagnosis or therapy of the indicating 2003, and April 26, 2003, while the research team was medical condition.’’14 These included abnormal labo- recruiting patients, were eligible for participation. We ratory values incurred because of medication admin- excluded patients who spoke neither English nor istration. Adverse drug interactions were defined as French, were physically unable to sign their name, ‘‘noxious and/or unintended effects caused by the co- presented for intentional self-poisonings, were pre- administration of two or more medications.’’ This viously enrolled, left against medical advice, or had included changes in the clinical efficacy of one or been seen by a physician involved in the study more medications caused by the coadministration of protocol and ADRE evaluation (CMH and JD). In another drug. Drug withdrawal reactions were con- addition, patients who demonstrated severe cognitive sidered whenever a medication that had been taken deficits (failed a Short Portable Mental State Ques- on a regular basis for at least one week had been tionnaire)13 and were unable to reflect understanding abruptly discontinued in the two weeks before the ED of this study by answering two questions about the visit. The presenting symptoms had to be consistent
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