It’s been over 6
years since we last discussed adverse events related to loading doses of
various medications (see our December 14, 2010 Patient Safety Tip of the Week “NPSA
(UK): Preventing Fatalities from Medication Loading Doses”).
But a recent AHRQ Web M&M brought the issue of
problematic loading doses to our attention again (Mucksavage 2017). A
patient with a known seizure disorder had a subtherapeutic
serum phenytoin level. A neurologist verbally recommended that she be re-loaded
with phenytoin. The ED physician ordered the correct loading dose of
intravenous (IV) phenytoin, to be administered every 8 hours for 3 doses. But
there was miscommunication and the patient was not switched back to a regular
maintenance dose after the 3 loading doses. So the patient continued to receive
IV phenytoin every 8 hours. And after 3 days developed signs and symptoms of
phenytoin intoxication. It was only then that the error was recognized.
Phenytoin, of
course, happens to be one of the medications most commonly involved in loading
dose errors. In our December 14, 2010 Patient Safety Tip of the Week “NPSA
(UK): Preventing Fatalities from Medication Loading Doses”) it was one of
the 4 medications most commonly involved in such events in the report by the UK
National Patient Safety Agency (NPSA 2010),
the other 3 being warfarin, amiodarone, and digoxin. In that NPSA report 11%
the loading dose was either repeated or continued incorrectly as the
maintenance dose as was done in the above case. The NPSA report also noted that
handovers and transitions of care were
particularly vulnerable to missed communications regarding
loading/maintenance doses.
Perhaps one of the unspoken issues about the safety of
loading doses is asking the question “Is
a loading dose of this medication really needed at this time?”. Over the years we’ve seen numerous instances where there
was probably overaggressive treatment that led to problems. To repeat from our December 14, 2010 Patient
Safety Tip of the Week “NPSA
(UK): Preventing Fatalities from Medication Loading Doses”: for phenytoin
the answer depends on the clinical circumstances. Obviously for true status
epilepticus an intravenous loading dose is appropriately indicated. But for a
patient who has had a single seizure (unless that seizure happens to occur
during neurosurgery) and is now back to their usual cognitive baseline, an
intravenous loading dose is probably not necessary. The gray zone would be in
the patient who has had a flurry of several seizures but does not meet the
definition of status epilepticus.
The rate of administration of IV phenytoin (and IV fosphenytoin) is the critical factor in producing
hypotension, bradycardia or cardiovascular collapse. The rate is not to
exceed 50 mg/min. in adults (1-3 mg/kg/minute in neonates) and should be by
a slow IV push, not an infusion. That means that for a typical loading
dose in an adult (1000-1500 mg), the physician would need to spend 20-30
minutes administering the drug. Over the years we’ve seen corners cut and
either the rate would be accelerated or an IV infusion would be used. Some of
that is because many neurologists have not seen significant cardiac side
effects from IV phenytoin. But those of us old enough to remember giving IV phenytoin
to cardiac patients (once upon a time it was used more frequently as a second-
or third-line antiarrhythmic agent) recall watching blood pressures bottom out
as we increased rates of the IV push. A recent study showed that 39% of
patients receiving an IV loading dose of fosphenytoin
had hypotension as an adverse effect (Clark 2016). An FDA review (FDA
2010) notes that the majority of cardiovascular deaths (for both IV
phenytoin and fosphenytoin) occurred in adults and at
recommended doses. Most had pre-existing cardiovascular disease.
Another key issue with phenytoin is use of the wrong
dilution technique. It is supposed to be given in normal saline, not glucose
solutions. Note also that intravenous phenytoin has been associated with the
“purple glove syndrome” (FDA
2010), a rare but serious condition. That was actually the primary reason
for the FDA safety review.
The Pennsylvania Patient Safety Authority (PPSA) published
one of its advisories on loading doses in 2012 (Carson
2012). They found 580 events related to loading doses over an 8-year period
in their Pennsylvania Patient Safety Reporting System (PA-PSRS). Over 70
medications were involved. Vancomycin was the drug most frequently involved,
accounting for 14.8% of reports. Ten of the top 20 medications in the PPSA
report were also in the top 20 in the UK NPSA study. These were amiodarone,
caffeine citrate, clopidogrel, digoxin, gentamycin,
heparin, magnesium sulfate, morphine, phenytoin, and vancomycin. Interestingly,
warfarin did not make the PPSA top 20 list (warfarin was the most frequently
involved drug in the UK NPSA study). Phenytoin was the only drug in the top 5
list in both studies, perhaps not surprisingly given that it is used
extensively.
Recognizing that you need to consider loading doses and
maintenance doses as part of a package, the PPSA report categorized the events
as follows:
Missed or omitted loading dose accounted for 25.5% of their
reports. Patient transfer, either within
or between facilities, was a major contributing factor. For example, the
loading dose is often ordered in the ED but the patient transferred prior to
receiving it and then only a maintenance dose is given at the destination. Wrong
loading doses were often related to the fact that dose calculations (based, for
example, on patient weight) are needed for many of the involved drugs. One
specific contributing factor the PPSA noted was that sometimes the pharmacy
would deliver a loading dose and maintenance dose to the unit at the same time
and staff on the unit would incorrectly select the maintenance dose. Loading
dose given multiple times accounted for 7% of reports in both the PPSA and UK
NPSA studies. Again, the patient transfer process was a contributing factor in
almost 20% of these cases. One factor we’d speculate about would be
non-integration of electronic medical records between the ED and the main
hospital. In the early days of electronic medical records and CPOE we often saw
implementation take place in a piecemeal fashion and ED’s often lagged behind
or even had different IT systems. So a loading dose given in the ED might not
be recorded in the inpatient IT system, creating the opportunity for the double
loading dose error.
Fortunately, two of the drugs most often mentioned in the UK
NPSA study have likely dropped significantly in rank of medications associated
with loading dose errors. First is digoxin. Its dropoff
has nothing to do with the risks of loading doses but rather with the
significant reduction in the use of digoxin over the last 2 decades.
Second is warfarin. Whereas typical practice years ago was
to give a loading dose of warfarin, wait a few days and then resume warfarin at
a maintenance dose based upon the INR result, such practice has largely changed.
A systematic review in 2010 (Heneghan 2010) concluded
that there is no advantage to loading patients with a 10 mg. dose compared to
starting with 5 mg. daily and they discouraged use of the 10 mg. dose,
particularly in elderly patients. The 10 mg. dose may or may not get the
patient to a therapeutic INR faster (depending on which study you read) but may
also be associated with early overanticoagulation and
there is even some theoretical concern that the loading may actually promote
the early hypercoagulability sometimes seen during warfarin initiation. But
there are still some who recommend a higher initial dose. More recent recommendations
(Witt 2016)
are:
Interestingly, both the CHEST guideline for VTE therapy (Kearon
2016) and the AHA/ACC/HFS guideline for management of atrial fibrillation (January 2014) are
silent on loading doses of warfarin. Warfarin loading doses are also becoming
less frequent because so many patients are instead being started on novel oral
anticoagulants (NOAC’s) instead of warfarin. In fact, that new VTE guideline suggests
use of non-vitamin K antagonist oral
anticoagulants (NOACs) over warfarin for initial and long-term treatment of VTE
in patients without cancer (see our February 2016 What's
New in the Patient Safety World column “Updated
VTE Guidelines from ACCP”).
Another drug that has often been associated with loading
dose errors is acetylcysteine, used for the treatment of acetaminophen
poisoning (Hayes
2008). The dosing regimen is complex, consisting of a loading dose followed
by 2 maintenance doses, each with different infusion rates.
As we noted above, transitions
of care may be particularly vulnerable
to errors related to loading doses. We’ve noted that mistakes commonly occur
with ED-to-inpatient transitions where
loading doses are ordered in the ED and the patient is admitted to the
hospital. Sometimes the loading dose is assumed to have been given in the ED
when, in fact, it was not. Other times the loading dose order is assumed to be
the maintenance dose order and very high doses are continued on a daily basis.
But another very vulnerable scenario is the LTC-to-ED-to-LTC scenario where a long-term care (LTC) patient is seen
in the ED but sent back to the LTC facility. Often the notes accompanying the
patient back to the LTC are insufficiently clear regarding the recommendations
for maintenance therapy and patients may end up getting high daily doses of the
medication. Don’t rely on just the written notes in such scenarios. A verbal communication
with the LTC facility to clarify dosing of that medication can go a long way to
avoiding errors.
Lastly, don’t forget the most common transition of care: ED-to-PCP or ED-to-SCP. We remain puzzled in this age of electronic medical
records how frequently the physicians responsible for the patient on a daily
basis (either the primary care physician or the specialist managing a
particular problem) are not made aware that their patient was even in the ED!
It’s rare enough that the PCP gets notified of the ED visit and sometimes the
PCP is notified but the specialist who is the prescriber of the medication at
issue does not get notified. Patients after an ED visit are often confused
about how to take their medications and may go home thinking they should
continue taking the higher dose given in the ED.
The following is a list of the previous NPSA and PPSA recommendations
supplemented with some of our own recommendations:
Technological solutions are obvious potential means to avoid
such errors. But does CPOE actually reduce the chance of errors with
loading doses or could it paradoxically increase that risk? We’ve seen some
pretty “clunky” IT systems that are not particularly user-friendly when it
comes to ordering medications. That is especially so when the order is a
complex one in which different doses of a drug are being given on different
days, as is the case with loading doses followed by maintenance doses.
Considerable confusion may occur when entering such orders, whether directly
entered by the physician or entered by a nurse or pharmacist. We have seen
instances where the loading dose of a drug gets continued every day or ones
where the patient gets both the loading dose and maintenance dose on the same
days. Theoretically, use of standardized order sets or protocols
(whether paper or electronic) may help avoid such errors but such have not
specifically been studied for drugs with loading doses.
The other problem, of course, is that clinical decision
support tools that can make CPOE and pharmacy computer systems safer are
still suboptimally used. Many current systems do not
provide dose range alerts that would flag a relatively high dose of a
medication for verification. Also, most current systems do not require an indication
field be filled out for each drug. A good system would require input of the
indication, with a check box or drop down list where “loading dose” could be
indicated (and the system programmed to not continue loading doses beyond the
specified time period).
Loading doses can even be a problem when they are not
loading doses! One of the medication error slides we like to show is a
hand-written prescription for 300 mg of an anticonvulsant that was intended to
be taken at bedtime. However, the “S” in “qHS” was
missing. The pharmacist interpreted the “qH” as “q4”
and assumed that “q4h” was intended. While the pharmacist recognized this would
be a very large dose of this anticonvulsant, he also assumed that this was
likely a loading dose. It was thus dispensed with the directions to “take every
4 hours” and the patient presented to the ER several days later with anticonvulsant
toxicity. We like this particular example because it demonstrates several
cognitive biases:
Loading doses are an error-prone facet of the medication
process, particularly at transitions of care, that
have been underrecognized but have the potential to
cause significant patient harm. You should consider adding an initiative on
loading doses to your medication safety program. At a minimum you should try to
get a handle on how often and for which drugs loading doses are being used in
your organization.
References:
Mucksavage JJ, Tesoro EP. Cases
& Commentaries. Hazards of Loading Doses. AHRQ Web M&M. Published
January 2017
https://psnet.ahrq.gov/webmm/case/396
NPSA (UK). Rapid Response Report. Preventing Fatalities from
medication loading doses. November 2010
http://www.nrls.npsa.nhs.uk/resources/?entryid45=92305
Rapid Response Report
supporting information
Clark SL, Leloux MR, Dierkhising RA, et al. IV fosphenytoin
in obese patients
Dosing strategies, safety, and efficacy. Neurology Clinical
Practice 2016; Published online before print November 4, 2016
http://cp.neurology.org/content/7/1/45
FDA (US Food and Drug Administration). Joint Meeting of the
Peripheral and Central Nervous System Drugs Advisory Committee and the Drug
Safety and Risk Management Advisory Committee. November 3, 2010
Carson SL, Gaunt MJ. Events associated with the prescribing,
dispensing, and administering of medication loading doses. PA-PSRS Patient Saf Advis 2012; 9: 82-88
September 2012
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Sep;9(3)/Pages/82.aspx
Heneghan C, Tyndel
S, Bankhead C, et al. Optimal loading dose for the initiation of warfarin: a
systematic review. BMC Cardiovascular Disorders 2010; 10:18
http://www.biomedcentral.com/1471-2261/10/18
Witt DM, Clark NP, Kaatz S, et al.
Guidance for the practical management of warfarin therapy in the treatment of
venous thromboembolism. J Thromb Thrombolysis 2016;
41: 187-205
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4715850/
Kearon C, Akl EA, Ornelas J, et
al. Antithrombotic Therapy for VTE Disease: CHEST Guideline. Chest 2016;
January 2016
http://journal.publications.chestnet.org/data/Journals/CHEST/0/11026.pdf
January CT, Wann LS, Alpert JS, et
al. 2014 AHA/ACC/HRS Guideline for the Management of Patients with Atrial
Fibrillation: Executive Summary. A Report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines and the
Heart Rhythm Society. Journal of the American College of Cardiology 2014; 64(21):
e1-e76
http://www.onlinejacc.org/content/64/21/2246
Hayes BD, Klein-Schwartz W, Doyon S. Frequency of medication
errors with intravenous acetylcysteine for acetaminophen overdose. Ann Pharmacother 2008; 42(6): 766-70
Print “March
2017 Loading Doses Again”
In our May 27, 2014
Patient Safety Tip of the Week “A
Gap in ePrescribing: Stopping Medications” we
highlighted what we consider to be a major flaw in current e-prescribing
systems, namely that they do not put the same emphasis on stopping medications
as they do on starting them.
In that column we
noted a case report in the Medical Journal of Australia (Tong
2014) in which discontinuation of one medication led to excessive levels of
a different medication because there had been a drug-drug interaction. And,
while there were clearly some communication issues that contributed to that
adverse event, we commented about the gaps in our information technology
systems that might have prevented it. Even though most regions are developing
HIE’s or RHIO’s that integrate health information from multiple sources, those
resources are often not routinely accessed by physicians and may not yet be
integrated into the EMR’s and e-prescribing systems in physician offices.
Moreover, e-prescribing integration with community pharmacies typically covers
medications ordered but seldom covers discontinuation of medications.
We also highlighted a critical issue: stopping a medication is much different than starting one. The
clinical decision support built into our EMR’s and e-prescribing systems
generally is pretty good at identifying potentially serious drug-drug
interactions and generating alerts at the time a medication is prescribed. That
presumes the alerts are turned on and the “severity” threshold for the
particular alert is enabled. (To avoid alert fatigue we usually recommend that
only the more serious alerts are enabled.)
But stopping a medication is much different. Most systems
are not programmed to generate any alerts at the time you discontinue a
medication. Hence, even if your system would have generated a drug-drug
interaction alert when you first prescribed a medication, it would not likely
generate an alert later when you discontinue that medication. Moreover,
starting a medication requires an active process – you either write a
prescription, enter one into a computer, or call the pharmacy. Whereas
discontinuing a medication is often more passive – you may just tell the
patient over the phone to stop it when the patient calls about a potential side
effect. You don’t call the pharmacy to stop it. And, if there was no associated
office visit, you might forget to update the patient’s medication list in your
EMR (or paper records) until the patient’s next office visit.
Another problem is that a patient may continue to get
medications that you thought you had stopped. A study done in a large
multispecialty group practice in Massachusetts (Allen 2012) showed
that among targeted medications that were electronically discontinued (on the
practice’s EMR) 1.5% were subsequently dispensed by a pharmacy at least once.
And this was just at the practice’s internal pharmacy. How often this happened
at community pharmacies was not known. Moreover, when they did manual chart
reviews of selected high-risk medications that had been discontinued they found
that 12% of cases were associated with potential harm.
The authors note that when a physician discontinues a
medication on an EMR he/she often (erroneously) assumes that such information
is being transmitted to the pharmacy. Such is seldom the case with today’s EMR
systems. Further, many pharmacies today have sophisticated systems that let you
know, as a patient, that you have a refill waiting for you at the pharmacy.
Patients may erroneously presume that their physician restarted that
medication.
And our February 28, 2017 Patient Safety Tip of the Week “The
Copy and Paste ETTO” reminds
us how the copy/paste function in today’s healthcare IT systems can lead to
erroneous medication lists that might result in a patient being inappropriately
restarted on a medication that had actually been discontinued.
Fischer and Rose (Fischer
2017) in a recent JAMA viewpoint article point out that outside of the VA
health system and a few integrated health systems, most US healthcare has
little or no capability for e-discontinuation. They note that it is common for
patients with chronic diseases to have prescription orders that may be
refillable for up to a year. And that the only way a physician can notify the
pharmacy of a medication discontinuation is to phone the pharmacy, which is
time-consuming and non-reimbursable, so few physicians do this when stopping a
patient’s medication. They note that a standard for e-discontinuation, called CancelRx, has been available for 2 decades as part of the
SCRIPT standard for e-prescribing. They further note that MACRA includes rules
that require EHR’s to include the ability to cancel prescriptions and other
features of the SCRIPT 10.6 standard. But its use by pharmacies is not mandated
and there is no way to ensure that pharmacies can receive and process such
messages.
Fischer and Rose note that this failure to integrate
e-discontinuation is occurring against a background where numerous online
pharmacies, chain pharmacies, and community pharmacies are contacting patients
by multiple means (phone, email, smartphone apps, etc.) to remind them to
refill their medications.
From the case
discussed earlier, it’s important when stopping a medication to look at all the
other medications a patient is taking and assess the likelihood that blood
levels or some physiologic effect may be altered when you stop this one
medication. Having clinical decision support tools available to help us spot a
drug-drug interaction that will disappear when stopping a drug would be very
helpful. Also when stopping a medication we always need to decide whether the
medication can simply be stopped all at once or whether it needs to be tapered
to prevent a withdrawal syndrome. Having a clinical decision support tool to
alert us when to taper would also be helpful. And, just as we do when starting
a drug, we need to tell the patient what symptoms or signs to watch out for and
what to do if they occur.
There is another
very important point we need to add to the process of e-discontinuation. Just
as we have advocated for inclusion of the indication for new prescriptions, it
is important that we always somehow record why we have discontinued a
medication. How often have you suggested a medication and your patient says
“yes, I was on that medication once" but can’t tell you why they were
taking it or why it was stopped. Was it simply not effective (for whatever
indication it was prescribed, which may not even be the reason you are now
recommending it) or was it stopped because of some unwanted effect? And was the
unwanted effect an allergic response, idiosyncratic response, an anticipated
side effect, or simply a dose-related side effect. It’s very important to have
details available about the reasons for discontinuation. Also, as we noted above,
medications are often discontinued at times when a physician or other
prescriber may not have access to the EHR or e-prescribing system. Often they
get a phone call from a patient and tell them over the phone to stop the
medication and then forget to record that in the patient record.
Too bad we’re not as
good at stopping medications as we are with starting them. Time to focus on all
aspects of the medication use process – including how to properly discontinue
them. Many articles have been written about the medication use process
including the following stages or phases: deciding about treatment, ordering or
prescribing, transcribing, preparing/dispensing, administering, and monitoring
(hospitals or pharmacies might also add at the beginning selection,
procurement, and storage). We could not find any that include discontinuation
as a stage or phase of the medication use
process. It’s time to add that.
And don’t forget
some of our past columns on deprescribing:
References:
Tong EY, Kowalski M, Yip GS, Dooley MJ. Impact of drug
interactions when medications are stopped: the often forgotten risks. Med J Aust 2014; 200 (6): 345-346
Allen AS, Sequist TD. Pharmacy
Dispensing of Electronically Discontinued Medications. Ann Intern Med 2012; 157(10): 700-705
http://annals.org/article.aspx?articleid=1391698
Fischer
S, Rose A. Responsible e-Prescribing Needs e-Discontinuation. JAMA 2017; 317(5):
469-470
http://jamanetwork.com/journals/jama/article-abstract/2600477
Print “March
2017 Yes! Another Voice for Medication e-Discontinuation!”
We’ve done numerous columns on the need to reduce the number
of unnecessary CT scans. Not only do unnecessary scans expose patients to
ionizing radiation but they add expense and often uncover incidental findings
that trigger the “diagnostic cascade” or “investigation momentum” where one
test leads to another and on and on…. Of course, there is probably an excess
performance of CT scans for most body parts but CT scans of the head are high
on the list of CT scans that are overused. So there have been numerous attempts
to develop ways of minimizing the ordering of unnecessary head CT scans.
One of the ways we’ve attempted to optimize the use of head
CT scans is using clinical decision rules. There’s no shortage of clinical
decision rules guiding the ordering of CT scans in patients with minor head
trauma. We have the Canadian CT Head Rule (Stiell
2001), the New Orleans Head CT Rule (Haydel 2000),
and the NICE guideline (NICE
2014) in adults. And for children we have CHIP (Smits
2007), CATCH (Osmond
2010), and the NICE guideline (NICE 2014).
A recent study looked at the appropriateness of head CT
scans for minor head trauma using the Canadian CT Head Rule (CCHR) as the
guideline (Klang 2017).
The authors retrospective reviewed 955 head CT scans and found 10.9% were not
indicated according to the CCHR. However, for patients under the age of 65,
37.3% of scans ordered were not indicated according to that rule. Looking at
factors associated with inappropriate ordering of head CT scans they found that
neurologists (present company, of course, excluded!) were 3.5 times more likely
to order them. Surgeons were statistically less likely to order. They did not
find any significant difference by seniority of the ordering physician. Also,
regarding injury mechanism, four-wheel motor vehicle accidents and being hit on
the head with an object were associated with higher rates of non-indicated CT
scans. Interestingly, motor vehicle accident as a pedestrian and two-wheel
vehicle driver were associated with lower rates of non-indicated CT scans. The
study did confirm that the CCHR had 100% sensitivity and 100% negative
predictive value for either brain hemorrhage or fractures. The authors do note
that its possible those cases where a neurologist was involved may have been more
complicated and perhaps could have had other indications for CT scanning. The
authors suggest that interventions to reduce the frequency of non-indicated
head CT scanning might include targeted education of staff members, protocol
implementation, and implementation of computerized decision rules.
A previous study had compared compare the cost-effectiveness
of using selective CT strategies with that of performing CT in all patients
with minor head injury (Smits 2010). Five
strategies were evaluated (1) CT performed in all patients with minor head
injury (2) selectively according to the New Orleans criteria (NOC) (3) selectively
according to the Canadian CT head rule (CCHR) (4) selectively according to the
CT in head injury patients (CHIP) rule or (5) in no patients. A Markov model
was used to analyze long-term costs and effectiveness. Results showed that performing
CT selectively according to the CCHR or the CHIP rule could lead to substantial
U.S. cost savings ($120 million and $71 million, respectively), and the CCHR was
the most cost-effective at reference-case analysis. When the prediction rule
had lower than 97% sensitivity for the identification of patients who required
neurosurgery, performing CT in all patients was cost-effective. The CHIP rule
was most likely to be cost-effective. The authors concluded that selecting
patients with minor head injury for CT renders cost savings and may be
cost-effective, provided the sensitivity for the identification of patients who
require neurosurgery is extremely high. But uncertainty regarding long-term
functional outcomes after minor head injury could justify the routine use of CT
in all patients with these injuries.
But there are numerous scenarios where these clinical
decision rules cannot be applied. For example, all those rules basically do not
apply to patients who are on anticoagulants. We’ve discussed CT scanning in
patients on anticoagulants (see the full list of prior columns below). But two
other scenarios not covered are: (1) the patient who is intoxicated and (2) the
patient first presenting to the ED beyond 24 hours.
Regarding the alcohol-intoxicated patient presenting to the
ED with altered mental status, a recent study provides some reassuring evidence
about timing of CT scanning (Granata
2017). The authors did a retrospective review of patients presenting
to the emergency department (ED) with altered mental status and alcohol
intoxication who had CT scanning at varying times after presentation. Of the
5943 patients included in the study none of those scanned in less than 3 hours
had intracranial findings on imaging requiring neurosurgery, whereas 1 patient
with a deferred CT scan required a neurosurgical intervention (which was not
emergently performed). The authors conclude that CT scanning of
alcohol-intoxicated patients with altered mental status is of low clinical
value and that deferring CT imaging while monitoring improving clinical status
appears to be a safe practice.
Another recent study looked at CT scanning in those patients
with head injury presenting more than 24 hours after the injury (Marincowitz
2016). They compared how the NICE guideline (NICE 2014) predicted
intracranial injuries in those patients presenting within or after 24 hours
from the injury. They found that 8.4%
of CT scans had traumatic abnormalities in those presenting within 24 hours and
9.9% in those presenting after 24 hours. The sensitivity of the
guidelines for intracranial injuries was 98% for those presenting within
24 h and 70% for those presenting after 24 h of injury. The
presence of a guideline indication did predict significant injury and this was
unaffected by time of presentation. The authors conclude that existing
guidelines appear to predict traumatic CT abnormalities irrespective of timing
of presentation but that their sole use in patients presenting after 24 hours
may result in significant injuries not being identified.
Some of our previous
columns on head trauma in the anticoagulated patient:
April 16, 2007 “Falls
With Injury”
July 17, 2007 “Falls
in Patients on Coumadin or Heparin or Other Anticoagulants”
June 5, 2012 “Minor
Head Trauma in the Anticoagulated Patient”.
July 8, 2014 “Update:
Minor Head Trauma in the Anticoagulated Patient”
References:
Stiell IG, Wells GA, Vandemheen K, et al for the CCC Study Group. The Canadian
CT Head Rule for patients with minor head injury. Lancet 2001; 357: 1391–96
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)04561-X/abstract
Haydel MJ, Preston CA, Mills TJ,
et al. Indications for Computed Tomography in Patients with Minor Head Injury.
N Engl J Med 2000; 343: 100-5 (New Orleans Head CT
Rule)
http://www.nejm.org/doi/full/10.1056/NEJM200007133430204
NICE (UK National Institute for Health and Care Excellence).
Head injury: assessment and early management. Clinical guideline [CG176] Published
date: January 2014
https://www.nice.org.uk/guidance/cg176
NICE imaging algorithm
https://www.nice.org.uk/guidance/cg176/resources/imaging-algorithm-498950893
Smits M, Dippel DWJ, Steyerberg EW, et al. Predicting Intracranial Traumatic
Findings on Computed Tomography in Patients with Minor Head Injury: The CHIP
Prediction Rule. Ann Intern Med. 2007; 146: 397-405
Osmond MH, Klassen TP, Wells GA, et
al. CATCH: a clinical decision rule for the use of computed tomography in
children with minor head injury. Can. Med. Assoc. J., Feb 2010; early release
published February 8, 2010 doi:10.1503/cmaj.091421
Klang E, Beytelman
A, Greenberg D, et al. Overuse of Head CT Examinations for the Investigation of
Minor Head Trauma: Analysis of Contributing Factors. J Amer
Coll Rad 2017; 14(2): 171-176 Published online:
November 8, 201
http://www.jacr.org/article/S1546-1440(16)30808-0/fulltext
Smits M, Dippel DWJ, Nederkoorn PJ. Minor Head Injury: CT-based Strategies for
Management—A Cost-effectiveness Analysis. Radiology 2010; 254: 532-540
http://radiology.rsna.org/content/254/2/532.abstract
Granata RT, Castillo EM, Vilke GM. Safety of deferred CT imaging of intoxicated
patients presenting with possible traumatic brain injury. Am J Emerg Med 2017; 35(1): 51-54
http://www.ajemjournal.com/article/S0735-6757(16)30680-5/fulltext
Marincowitz C, Allgar
V, Townend W. CT Head Imaging in Patients With Head
Injury Who Present After 24 h of Injury. A Retrospective Cohort Study. Emerg Med J 2016; 33(8): 538-542
http://emj.bmj.com/content/33/8/538.abstract?sid=8b331e32-b9f4-4fc6-b69d-947429c8dd23
Print “March
2017 Update on CT Scanning after Minor Head Trauma”
We’ve done many
columns on handoffs/handovers and are advocates of using structured tools to
facilitate such. There is certainly no shortage of structured tools and formats
for handoffs (see our February 14, 2012 Patient Safety Tip of the Week “Handoffs
– More Than Battle of the Mnemonics” and the many columns listed below).
One problem we’ve
always encountered is that some patients may get “shortchanged” in such
handoffs depending upon time limitations and the order of prioritization, i.e.
patients discussed earlier in the handoff tend to be discussed in more detail.
In our January 29, 2013 Patient Safety Tip of the Week “A
Flurry of Activity on Handoffs” we noted a handoff study (Cohen
2012) which showed that in intensive care unit attending-to-attending
handoffs at the end of the week, patients discussed earlier had a
disproportionate amount of time allocated. This finding was irrespective of the
severity or complexity of the patient’s case. Cases earliest in the handoff
sessions had about 50% more time in discussion that those discussed toward the
end of the handoff.
Now a new study has
looked at the impact of two structured handoff tools on multidisciplinary
rounds (Abraham 2016).
The researchers compared multidisciplinary rounds (MDR’s) in two comparable
MICU’s in an academic medical center. One group used a traditional SOAP format
(like we’ve used in progress notes for many years). The other used HAND-IT (Abraham 2012),
a tool organized by body systems. They then recorded MDR’s and analyzed them
for total duration, duration for individual patients, and
interruptions/distractions unrelated to the patient being discussed. They did
not find that the order of patient presentation impacted time spent on the
patient or communication breakdowns. However, for the problem-based (SOAP) tool, there was a significant linear
relationship between the time spent on discussing a patient and the number of
communication breakdowns. This effect was much less when using the HAND-IT
tool. They note that the HAND-IT tool “required more effort and time to gather
and document information, but it reduced the time spent and additional effort
during rounds to address the information gaps.”
So add one more tool and mnemonic to your handoff toolkit!
Read about many other
handoff issues (in both healthcare and other industries) in some of our
previous columns:
May 15, 2007 “Communication,
Hearback and Other Lessons from Aviation”
May 22, 2007 “More
on TeamSTEPPS™”
August 28, 2007 “Lessons
Learned from Transportation Accidents”
December 11,
2007 “Communication…Communication…Communication”
February 26, 2008
“Nightmares….The
Hospital at Night”
September 30, 2008 “Hot
Topic: Handoffs”
November 18, 2008 “Ticket
to Ride: Checklist, Form, or Decision Scorecard?”
December 2008 “Another
Good Paper on Handoffs”.
June 30, 2009 “iSoBAR:
Australian Clinical Handoffs/Handovers”
April 25, 2009
“Interruptions,
Distractions, Inattention…Oops!”
April 13, 2010 “Update
on Handoffs”
July 12, 2011 “Psst!
Pass it on…How a kid’s game can mold good handoffs”
July 19, 2011 “Communication
Across Professions”
November 2011 “Restricted
Housestaff Work Hours and Patient Handoffs”
December 2011 “AORN
Perioperative Handoff Toolkit”
February 14, 2012
“Handoffs
– More Than Battle of the Mnemonics”
March 2012 “More
on Perioperative Handoffs”
June 2012 “I-PASS
Results and Resources Now Available”
August 2012 “New
Joint Commission Tools for Improving Handoffs”
August 2012 “Review
of Postoperative Handoffs”
January 29, 2013 “A
Flurry of Activity on Handoffs”
December 10, 2013 “Better
Handoffs, Better Results”
February 11, 2014 “Another
Perioperative Handoff Tool: SWITCH”
March 2014 “The
“Reverse” Perioperative Handoff: ICU to OR”
September 9, 2014 “The
Handback”
December 2014 “I-PASS
Passes the Test”
January 6, 2015 “Yet
Another Handoff: The Intraoperative Handoff”
References:
Cohen MD, Ilan R, Garrett L, et
al. The Earlier the Longer: Disproportionate Time Allocated to Patients
Discussed Early in Attending Physician Handoff Sessions. Arch Intern Med 2012;
172(22): 1762-1764
http://archinte.jamanetwork.com/article.aspx?articleid=1391009#qundefined
Abraham J, Kannampallil TG, Patel
VL, et al. Impact of Structured Rounding Tools on Time Allocation During
Multidisciplinary Rounds: An Observational Study. JMIR Hum Factors 2016; 3(2):
e29
https://humanfactors.jmir.org/2016/2/e29/
Abraham J, Kannampallil T, Patel
B, et al. Ensuring Patient Safety in Care Transitions: An Empirical Evaluation
of a Handoff Intervention Tool. AMIA Annu Symp Proc 2012; 2012: 17-26
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3540511/
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2017 Adding Structure to Multidisciplinary Rounds”
Print “March
2017 What's New in the Patient Safety World (full
column)”
Print “March
2017 Loading Doses Again”
Print “March
2017 Yes! Another Voice for Medication e-Discontinuation!”
Print “March
2017 Update on CT Scanning after Minor Head Trauma”
Print “March
2017 Adding Structure to Multidisciplinary Rounds”
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