For a long time weve felt that performance measures for VTE
prophylaxis may be resulting in many low-risk patients receiving unnecessary
prophylaxis. Now another study has questioned whether we are overusing
prophylaxis in general medical patients. Flanders et al reported the results of
a large multihospital performance improvement collaborative in Michigan (Flanders
2014). They looked at VTE events occurring within 90 days of hospital
admission and stratified the results by hospital performance on a VTE
prophylaxis measure. Overall, the rate of VTE events in this medical population
was very low. When stratified into tertiles
(prophylaxis rates 85.8%, 72.6% and 55.5% for high, moderate and low hospitals
respectively) they found no difference in the VTE rates. Their results suggest
that efforts to increase the rates of VTE prophylaxis in non-critically ill
general medical patients may not substantially reduce the rate of VTE.
The accompanying commentary (Rothberg
2014) is also very thoughtful. One interpretation is that giving
prophylaxis to large numbers of low-risk medical patients does not
significantly reduce VTE and exposes patients unnecessarily to painful
injections, creates excess costs and might increase the risk of bleeding.
Rothberg notes that the fundamental problem is lack of validated tools for risk
assessment in this population. The Caprini model has
been validated in surgical, but not medical, patients. Rothberg suggests that the
Padua Prediction Score (recommended in the most recent ACCP guidelines for VTE
prophylaxis) might prove to be a better tool in medical patients but still
needs to be validated in a medical population in the US because of differences
between patients in the Italy and the US.
Our April 2014 Whats
New in the Patient Safety World column Another
Rap on the VTE Prophylaxis Measure discussed another study that
questioned the utility of the VTE prophylaxis measure (JohnBull
2014). Those authors used publicly reported data from CMS to see if
there was a correlation between VTE prophylaxis rates and outcome rates and
found no correlation. They found that VTE rates at hospitals reporting 100%
compliance with VTE prophylaxis were no different than those at hospitals in
the bottom quintile of prophylaxis rates.
In our February 15,
2011 Patient Safety Tip of the Week Controversies
in VTE Prophylaxis we highlighted a study by some very respected
investigators in the surgical quality improvement field (Qadan
2011) that questioned the current recommendations on venous thrombembolism (VTE) prophylaxis in elective major
surgery. The authors collected data on DVT and PE in patients electively
undergoing 4 major surgical procedures (colorectal resection, total knee
replacement, total hip replacement, and hysterectomy) from a large database
from a consortium of academic medical centers for two periods of time
(2003-2004 vs. 2007-2008). The study demonstrated a substantial increase in the
use of pharmacologic DVT prophylaxis between the two time periods. Yet the
rates of DVT and PE were not significantly impacted by this increased use of
such prophylaxis. Moreover, the overall rates of DVT and PE were actually
quite low and the rates in patients who did not receive pharmacoprophylaxis
actually decreased between the two time periods. The authors concluded that
this may show that clinical judgment of physicians in choosing which patients
need pharmacoprophylaxis is remarkable.
In our November 2013
Whats New in the Patient Safety World column Are
VTE Measures Flawed as Quality Measures? we highlighted a study (Bilimoria
2013) that looked at
almost a million surgical patients in almost 3000 hospitals for VTE prophylaxis
rates, VTE event rates, and use of imaging in VTE screening. They found that greater
hospital VTE prophylaxis adherence rates were weakly associated with worse
risk-adjusted VTE event rates. When they looked at hospitals with higher
structural quality scores (based on 8 factors commonly thought to be
associated with higher commitment to quality) they found higher VTE prophylaxis adherence rates but worse risk-adjusted VTE
rates. Risk-adjusted VTE rates increased significantly with VTE imaging use
rates in a stepwise fashion, leading to their conclusion that surveillance bias limits the usefulness
of the VTE quality measure for hospitals.
The time has come to refine the VTE prophylaxis performance
measures to ensure that we are not creating unintended consequences. It would
not be the first time performance measures have created such. We all recall the
original CMS measure for prompt antibiotic administration in patients with
community acquired pneumonia resulted in many patients not having pneumonia at
all receiving unnecessary antibiotics.
But critical to refining the VTE prophylaxis measure, if it
is to be kept at all, will be to standardize on a validated risk assessment
tool and remove the surveillance bias that may affect rates.
Some of our prior
columns on issues related to VTE prophylaxis measures:
February 15, 2011 Controversies
in VTE Prophylaxis
November 2013 Are
VTE Measures Flawed as Quality Measures?
April 2014 Another
Rap on the VTE Prophylaxis Measure
References:
Flanders SA, Greene T, Grant P, et al. Hospital
Performance for Pharmacologic Venous Thromboembolism Prophylaxis and Rate of
Venous Thromboembolism. A Cohort Study. JAMA Intern Med. 2014; 174(10):
1577-1584
http://archinte.jamanetwork.com/article.aspx?articleid=1897547
Rothberg MB. Venous Thromboembolism Prophylaxis for Medical PatientsWho Needs It? JAMA Intern Med 2014; 174(10):
1585-1586
http://archinte.jamanetwork.com/article.aspx?articleid=1897540
Qadan M, Polk HC, Hohmann
SF, Fry DE. A reassessment of needs and practice patterns in pharmacologic
prophylaxis of venous thromboembolism following elective major surgery. Ann Surg 2011; 253(2): 215-220
JohnBull EA, Lau BD, Schneider EB,
et al. No Association Between Hospital-Reported
Perioperative Venous Thromboembolism Prophylaxis and Outcome Rates in Publicly
Reported Data (Research Letter). JAMA Surgery 2014; online first February 5,
2014
http://archsurg.jamanetwork.com/article.aspx?articleid=1818821
Bilimoria KY, Chung J, Ju
MH, et al. Evaluation of Surveillance Bias and the Validity of the Venous Thromboembolism
Quality Measure. JAMA 2013; 310(14): 1482-1489
http://jama.jamanetwork.com/article.aspx?articleid=1748150&resultClick=1
Print November
2014 VTE Prophylaxis Debate Continues
A new study investigated out-of-hospital medication errors
involving children (Smith
2014). The investigators used a database of reports from poison control
centers nationwide. Between 2002 and 2012 they found 63,000 such errors
annually in children under the age of 6 or one error every 8 minutes in the US.
They acknowledge this is likely an underestimate since the database captures
only those cases that were reported to poison control centers.
Most of the incidents (96.9%) occurred in the childs own
home but some occurred in other residences or in school. Fortunately, most did
not cause serious harm to children and most did not require management or
monitoring in a healthcare facility. Analgesics, cough and cold preparations,
antihistamines and antibiotics accounted for the vast majority of incidents. Boys
accounted for a slightly higher percentage of cases and there was a seasonal
pattern with higher incidence in winter (more prescriptions for offending
medications occur during winter months). The percentage due to cough and cold
preparations decreased considerably over the study period, largely due to
efforts to reduce their inappropriate prescription.
Being inadvertently given a medication twice accounted for
27% of medication errors, followed by other incorrect dose (17.8%), confused
units of measure (8.2%), and wrong medication (7.8%).
The incidence of medication errors increased in younger
children, with more than 25% of cases occurring in children under the age of 1
year. Liquid medications were more often involved in younger patients.
The authors note several opportunities to reduce the
occurrence of such medication errors in children. Efforts at educating parents
on correct use of dosing devices and better instructions on labeling and
packaging are important. Moreover, adherence to evidence-based guidelines for
prescription of drugs in the analgesic, antihistamine, and antimicrobial
categories should be emphasized.
Language barriers, of course, may play a role in pediatric
medication errors. So may health literacy issues. For years when we have talked
about health literacy we have focused on reading levels and reading
comprehension. But in our June 2012 Whats
New in the Patient Safety World column Parents'
Math Ability Matters we noted a study (AAP
2012) that showed that parents mathematics skills, independent of reading
skills, may play a big role in some pediatric medication errors. The study was
done by Marrese et al. and presented as an abstract at the
Pediatric Academic Societies (PAS) annual meeting April 28, 2012 (Marrese 2012). It showed parents with math skills
at the third grade level or below were five times more likely to measure the
wrong dose of medication for their child than those with skills at the sixth
grade level or higher. While
about a third of the parents had low reading skills, 83% had poor numeracy skills, with 27% having
skills at or below the third grade level. Parents with low numeracy may
especially prone to make errors in tasks requiring dose measurement or
measurement conversions.
The study highlights the need to address numeracy skills of
parents when communicating medication instructions (we suspect the same is
likely to apply to adult medication errors as well). They also provide as an example
having providers review and give parents pictures of dosing instruments filled
to the correct amount for that prescription.
And a study earlier this year showed that parents
measurement and dosing errors are common (Yin
2014). 39.4% of parents made an error in measurement of the intended dose
and 41.1% made an error in the prescribed dose. Furthermore, 16.7% used a
nonstandard instrument. Compared with parents who used milliliter-only, parents
who used teaspoon or tablespoon units had twice the odds of making an error
with the intended and prescribed dose. Associations were greater for parents
with low health literacy and nonEnglish speakers. Nonstandard instrument use
partially mediated teaspoon and tablespoonassociated measurement errors. The
authors conclude that their findings support a milliliter-only standard to
reduce medication errors.
We also refer you to our May 7, 2013 Patient Safety Tip of
the Week Drug
Errors in the Home which had many observations and recommendations
regarding pediatric patients in the home as well as adult patients.
Some of our other
columns on pediatric medication errors:
November 2007 1000-fold
Overdoses by Transposing mg for micrograms
December 2007 1000-fold
Heparin Overdoses Back in the News Again
September 9, 2008 Less
is More and Do You Really Need that Decimal?
July 2009 NPSA
Review of Patient Safety for Children and Young People
June 28, 2011 Long-Acting
and Extended-Release Opioid Dangers
September 13, 2011 Do
You Use Fentanyl Transdermal Patches Safely?
September 2011 Dose
Rounding in Pediatrics
April 17, 2012 10x
Dose Errors in Pediatrics
May 2012 Another
Fentanyl Patch Warning from FDA
June 2012 Parents
Math Ability Matters
Septembrer 2012 FDA
Warning on Codeine Use in Children Following Tonsillectomy
May 7, 2013 Drug
Errors in the Home
May 2014 Pediatric
Codeine Prescriptions in the ER
References:
Smith MD, Spiller HA, Casavant MJ,
et al. Out-of-Hospital Medication Errors Among Young
Children in the United States, 2002-2012. Pediatrics 2014; 134: 867876 published online October
20, 2014
http://pediatrics.aappublications.org/content/early/2014/10/15/peds.2014-0309.full.pdf+html
American Academy of
Pediatrics (AAP). Parents Poor Math Skills May Lead to Medication Errors. AAP
press release April 28, 2012
Marrese C, Dreyer B, Mendelsohn A, Moreira H, Yin
HS. Parent Medication Dosing
Errors: Role of Health Literacy and Numeracy (abstract). Pediatric Academic Societies (PAS) annual
meeting April 28, 2012
http://www.abstracts2view.com/pas/view.php?nu=PAS12L1_4021
Yin HS, Dreyer BP, Ugboaja DC, et
al. Unit of Measurement Used and Parent Medication Dosing Errors. Pediatrics 2014; 134(2): e354-e361;
published ahead of print July 14, 2014
Print November
2014 Out-of-Hospital Pediatric Medication Errors
In our July 1, 2014
Patient Safety Tip of the Week Interruptions
and Radiologists we took a look at the impact of interruptions and
distractions on the workflow of radiologists. A study (Yu 2014)
found that during a typical 8PM to 8AM overnight shift there was an average of
72 telephone calls, with a median call duration 57 seconds, and the average
time spent on the phone was 108 minutes. The median interval from the start of
one telephone call to the start of the next ranged from 3 to 10 minutes,
depending on the time of day. There was also a correlation between volume of
phone calls and the volume of CT scans being done (volume of other imaging
studies was not measured as part of this study). That study did not include any
measure of image interpretation accuracy or disparities between interpretations
by the on-call radiologist and any subsequent interpretations.
But now another study has looked at the impact of telephone
calls on radiology residents on-call to determine whether there was a
relationship between these and discrepancies on reports (Balint
2014). While there was a only a slight difference in total phone
calls per shift between those shifts with and without report discrepancies,
there was a statistically significant
increase in the average number of phone calls in the 1 hour preceding the
generation of a discrepant preliminary report (4.23 vs. 3.24 calls). The
authors suggest that one additional phone call during the hour preceding the
generation of a discrepant preliminary report resulted in a 12% increased likelihood
of a resident error.
One of the
strategies they recommend to prevent such interruptions is to have other staff
handle phone calls. Additonal potential strategies
include interruption-free zones and having a separate radiologist or radiology
resident handle consultations. The previous study by Yu and colleagues
noted that posting preliminary reports on the electronic medical record has
likely had a beneficial effect on frequency of calls. They, too, have also
begun having medical students assist the on-call radiologist by answering the
phone and triaging imaging reports. We added that radiology physician
assistants can help with things like contrast injections, etc. during high
activity periods that might also interrupt radiologists reading. Hospitals
having the luxury of larger radiology staffs might have a dedicated second
radiologist during high volume periods whose sole responsibility is
interpreting images. Note that the latter might also be reading images off-site
via teleradiology.
We also stressed that much time can be wasted in tracking
down the appropriate physician when communicating significant findings. So
anything you can do to facilitate identification of the responsible physician
would be a positive step.
Prior Patient Safety
Tips of the Week dealing with interruptions and distractions:
References:
Yu J-P, Kansagra AP, Morgan J. The
Radiologist's Workflow Environment: Evaluation of Disruptors and Potential
Implications. JACR 2014; published online April 26, 2014
http://www.jacr.org/article/S1546-1440%2813%2900850-8/pdf
Balint BJ, Steenburg
SD, Lin H, et al. Do Telephone Call Interruptions Have an Impact on
Radiology Resident Diagnostic Accuracy? Academic Radiology 2014; published
online September 30, 2014
http://www.academicradiology.org/article/S1076-6332%2814%2900307-9/abstract
Print November
2014 More Radiologist Interruptions
In our August 2014 Whats New in the Patient Safety World column A
New Rapid Screen for Delirium in the Elderly we discussed the importance
of recognizing delirium but that delirium goes unrecognized or undiagnosed in
up to 72% of cases in hospitalized patients (Collins
2010). One of the reasons may be that commonly used screening tests for
delirium may not be brief enough or may require specific training for
administration. We noted a new screening tool, the 4 As Test (4AT) to help improve screening
for delirium and its validation in a population other than that in which it was
developed (Bellelli
2014).
Now another brief diagnostic tool for delirium, the 3D-CAM,
has been derived and validated (Marcantonio 2014).
The assessment takes only about 3 minutes to administer and can be administered
by a wide variety of healthcare workers. It takes less than an hour to train
someone to administer the tool.
In the validation study, the 3D-CAM had a sensitivity of 95%
and specificity of 94% and performed almost equally well in patients with and
without dementia (specificity in patients with dementia was slightly less at
86% but sensitivity was 96%). Importantly, the vast majority of patients
identified as having delirium had either the hypoactive variety or normal
psychomotor activity. That is the population in which delirium is often
undiagnosed, compared to those with the hyperactive variety.
The 3D-CAM
instrument and training manual are available on the Hospital Elder Life
Program website. The authors note that the structured
nature of the instrument also make it possible to administer via an electronic
platform, such as mobile technology.
Since the study was done on general medical patients, it
should be validated on other populations (eg.
surgical patients, other types of hospitals, etc.) before being used in those
settings.
Like the previously discussed 4AT tool, the 3D-CAM is
simple, easy to administer, does not require extensive training, has good
sensitivity and specificity, and works in patients with and without dementia.
We fully expect that these much simpler tools should vastly improve the early
detection and management of delirium.
Some of our prior
columns on delirium assessment and management:
·
October
21, 2008 Preventing
Delirium
·
October
14, 2009 Managing
Delirium
·
February
10, 2009 Sedation
in the ICU: The Dexmedetomidine Study
·
March
31, 2009 Screening
Patients for Risk of Delirium
·
June 23,
2009 More
on Delirium in the ICU
·
January
26, 2010 Preventing
Postoperative Delirium
·
August
31, 2010 Postoperative
Delirium
·
September
2011 Modified
HELP Helps Outcomes in Elderly Undergoing Abdominal Surgery
·
December
2010 The
ABCDE Bundle
·
February
28, 2012 AACN
Practice Alert on Delirium in Critical Care
·
April 3, 2012 New
Risk for Postoperative Delirium: Obstructive Sleep Apnea
·
August
7, 2012 Cognition,
Post-Op Delirium, and Post-Op Outcomes
·
September
2013 Disappointing
Results in Delirium
·
October
29, 2013 PAD:
The Pain, Agitation, and Delirium Care Bundle
·
February
2014 New
Studies on Delirium
·
March
25, 2014 Melatonin
and Delirium
·
May 2014
New
Delirium Severity Score
·
August
2014 Delirium
in Pediatrics
·
August
2014 A
New Rapid Screen for Delirium in the Elderly
References:
Collins N, Blanchard MR, Tookman
A, Sampson EL. Detection of delirium in the acute hospital. Age Ageing 2010; 39 (1): 131-135
http://ageing.oxfordjournals.org/content/39/1/131.full.pdf+html
The 4 As Test: screening instrument for delirium and
cognitive impairment
Bellelli G, Morandi
A, Davis DHJ, et al. Validation of the 4AT, a new instrument for rapid delirium
screening: a study in 234 hospitalised older people. Age Ageing 2014; 43(4): 496-502
http://ageing.oxfordjournals.org/content/43/4/496.full.pdf+html
Marcantonio ER, Ngo LH, O'Connor
M, et al. 3D-CAM: Derivation and Validation of a 3-Minute Diagnostic Interview
for CAM-Defined Delirium: A Cross-sectional Diagnostic Test Study. Ann Intern Med 2014; 161(8): 554-561
http://annals.org/article.aspx?articleid=1916821
3D-CAM (3 minute diagnostic assessment). The Hospital Elder
Life Program 2014.
http://www.hospitalelderlifeprogram.org/delirium-instruments/3dcam/
Print November
2014 The 3D-CAM for Delirium
Print November
2014 What's New in the Patient Safety World (full
column)
Print November
2014 VTE Prophylaxis Debate Continues
Print November
2014 Out-of-Hospital Pediatric Medication Errors
Print November
2014 More Radiologist Interruptions
Print November
2014 The 3D-CAM for Delirium
Print November
2014 What's New in the Patient Safety World (full
column in PDF version)
http://www.patientsafetysolutions.com/