A number of years
ago when a healthcare quality consortium was looking for a project, we proposed
they study the patterns of CT scan usage in children across regional hospitals.
We strongly suspected that efforts to minimize the use of ionizing radiation in
children were probably less developed in non-pediatric facilities. The
consortium chose another project but a recent study has demonstrated that, at
least for cranial CT scans in children with trauma, the dose of radiation
received at non-pediatric hospitals is roughly twice that at pediatric trauma
centers.
Nabaweesi and colleagues (Nabaweesi
2017) looked at injured children younger than 18 years who received a CT
scan at a referring hospital and were subsequently transferred to a pediatric
trauma center. The median effective
radiation dose received at non-pediatric hospitals was twice that received at
the pediatric trauma center (3.8 versus 1.6 mSv). Their results were confirmed
even after controlling for mode of transportation, emergency department
disposition, level of injury severity, non-pediatric hospital trauma center
level, hospital type, size, region, and radiology services location. The
authors strongly suggest adoption of pediatric CT protocols.
Nabaweesi and colleagues note that use of cranial CT scans
in children has been increasing, in part due to increased awareness of
sports-related concussions.
Much of the focus on the risks of ionizing radiation
exposure in children has focused on avoiding unnecessary imaging, CT scanning
in particular because of its relatively high levels of radiation. We’ve
discussed in prior columns programs like Imaging Gently® and also use of clinical decision rules to help
guide decisions about imaging (see for example our September 2017 What's New in the Patient Safety World column “Clinical
Decision Rule Success”).
The New Jersey
Hospital Association has recently led a collaborative to reduce unnecessary
radiation exposure from CT scanning in children (NJHA
2017a). They sought to standardize
protocols for head CT scans in children, for both the decision-making process (clinical
observation criteria and an algorithm) and for the proper radiation dosage. NJHA
created a laminated pocket card of the algorithm and shared it with emergency
room physicians and nurses across the state and partnered in a number of
education programs.
Twelve months later,
new data shows that avoidable pediatric head CT scans decreased by 25 percent
in New Jersey hospitals.
Now they have developed a #SCANSMART Toolkit (NJHA 2017b) and
have shifted focus to the community, educating parents, coaches, trainers and others with posters and pamphlets
highlighting both the benefits and risks of CT imaging.
Some of our previous
columns on the issue of radiation risk:
References:
Nabaweesi R, Ramakrishnaiah RH, Aitken ME, et al. Injured
Children Receive Twice the Radiation Dose at Nonpediatric Trauma Centers
Compared With Pediatric Trauma Centers. J Am Coll Radiol 2017; Published
online: August 25, 2017
http://www.jacr.org/article/S1546-1440(17)30825-6/fulltext
Imaging Gently®
NJHA (New Jersey Hospital Association). ScanSmart: New
Patient Safety Initiative Calls for Cool Heads When Using CT Scans on Kids. PR
Newswire 2017; Sep. 14, 2017
NJHA (New Jersey Hospital Association) Institute for Quality
and Patient Safety. #SCANSMART – Safe CT Imaging.
http://www.njha.com/pfp/njtools/safe-ct-imaging/
Print “November
2017 SCANSMART Program to Use CT Safely in Children”
It’s well known that certain drugs, like benzodiazepines and
barbiturates, have respiratory depressant effects that may be additive when
patients are also receiving opioids. However, one commonly prescribed drug in
pain patients has been flying under the radar with regard to its additive
effects in producing respiratory depression. Gabapentin is prescribed
frequently in patients with certain types of chronic pain. It’s generally
perceived by physicians as being a relatively safe drug. However, a recent
Canadian study (Gomes
2017) found that among patients receiving prescription opioids, concomitant
treatment with gabapentin was associated with a substantial increase in the
risk of opioid-related death
Cases, taken from an Ontario, Canada administrative
database, were defined as opioid users who died of an opioid-related cause. These
were matched with up to 4 controls who also used opioids on age, sex, year of
index date, history of chronic kidney disease, and a disease risk index. After
matching there were 1,256 cases and 4,619 controls for analysis. 12.3% of cases
and 6.8% of controls were prescribed gabapentin in the prior 120 days. After
multivariable adjustment, co-prescription of opioids and gabapentin was
associated with a significantly increased odds of opioid-related death (odds
ratio 1.99 and adjusted OR 1.49) compared to opioid prescription alone.
Moderate-dose and high-dose gabapentin use was associated with a nearly 60%
increase in the odds of opioid-related death relative to no concomitant
gabapentin use.
Overall, co-prescription was associated with a 50% increase
in the risk of dying of opioid-related causes and a very high dose of
co-prescribed gabapentin was associated with a near doubling of this risk.
Combined use of gabapentin and opioids is not uncommon. In
the Ontario database noted above, 46.0% of gabapentin users received at least 1
concomitant prescription for an opioid.
Note that this study only looked at use of gabapentin. It
did not evaluate those using pregabalin, the precursor of gabapentin that is
more widely prescribed for certain types of chronic pain in the US.
Though this study demonstrates an association between
concomitant use of gabapentin and opioids and death from opioid-related causes,
it does not prove causality. Nevertheless, this study raises a red flag about
the concomitant use of these drugs. The authors recommend strategies for
minimizing the sequelae of this interaction should be considered, including
cautious dose titration, dose adjustment in the setting of co-morbid lung and
kidney disease, and avoidance of other CNS depressants. In addition, patients
treated with this combination should be instructed to seek medical attention
immediately if symptoms of opioid overdose occur.
Given the likelihood that many physicians are unaware of
this potential interaction and additive effect, this may represent an
opportunity of clinical decision support tools (in either CPOE or e-prescribing
systems) to alert prescribers when an opioid is being started in a patient who
is already receiving gabapentin or vice versa.
References:
Gomes T, Juurlink DN, Antoniou T, et al. Gabapentin,
opioids, and the risk of opioid-related death: A population-based nested
case–control study. PLOS Medicine 2017; Published: October 3, 2017
http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002396
Print “November
2017 Bad Combination: Gabapentin and Opioids”
We’ve done several
columns highlighting reports where insulin pens were inappropriately used on
multiple different patients. But a new study (Kossover-Smith
2017) found that unsafe injection
practices are both commonplace and not confined to misuse of insulin pens.
Kossover-Smith and colleagues surveyed physicians and nurses
about injection practices and found that 12% of physicians and 3% of nurses indicated syringe reuse occurs in
their workplace. Unsafe injection practices were reported by both
physicians and nurses across all surveyed physician specialties and nurse
practice locations. Even more surprisingly, nearly 5% of physicians indicated
this practice usually or always occurs. A higher proportion of oncologists
reported unsafe practices occurring in their workplace.
The authors conclude that, since their survey revealed
dangerous provider misperceptions and behaviors, further research into ways to
modify behaviors is needed. Provider campaigns, such as the One & Only Campaign, are
available to support safe practices in any setting where injections are delivered.
That campaign emphasizes “one needle, one syringe, only one time”.
Some of our prior
columns highlighting the safety issues of insulin, insulin pumps, insulin pens
and similar devices:
November 2, 2010 “Insulin:
Truly a High-Risk Medication”
September 18, 2012 “Insulin
Pump Safety”
February 26, 2013 “Insulin
Pen Re-Use Incidents: How Do You Monitor Alerts?”
April 2013 “More
Tips on Insulin Pen Safety”
April 2014 “Insulin
Pens - Again”
July 2014 “Joint
Commission Sentinel Event Alert: Don’t Misuse Vials”
March 10, 2015 “FDA
Warning Label on Insulin Pens: Is It Enough?”
April 14, 2015 “Using
Insulin Safely in the Hospital”
References:
Kossover-Smith RA, Coutts K, Hatfield, KM, et al. One
needle, one syringe, only one time? A survey of physician and nurse knowledge,
attitudes, and practices around injection safety. Am J Infect Control 2017;
45(9): 1018-1023
http://www.ajicjournal.org/article/S0196-6553(17)30680-6/fulltext
One & Only
Campaign.
http://www.oneandonlycampaign.org/
Print “November
2017 Syringe Re-Use Surprisingly Common”
A couple months ago we did a column on adverse events in
neurological inpatients (see our August
2017 What's New in the Patient Safety World column “Adverse
Events in Hospitalized Neurological Patients”), noting that there has
been a relative paucity of studies on patient safety issues in neurological
patients.
In that column we
noted neurological conditions that require hospitalization have a number of
features that predispose to a variety of potential adverse events. For example,
many are associated with neurogenic bladder dysfunction that may be a factor in
high rates of catheter-associated urinary tract infections (CAUTI’s). Many of
the conditions are associated with reduced mobility, increasing the risk for
pressure ulcers and DVT and venous thromboembolism. Some (eg. stroke,
Parkinson’s) may be associated with disordered swallowing that predisposes to
aspiration and pneumonia. Impairment of balance and/or righting reflexes may
lead to falls. Those neurological conditions that impair cognition may also
predispose to delirium when other medical insults occur. And several
neurological conditions may be associated with obstructive sleep apnea, which
may increase the risk of respiratory depression in relation to opioids or other
drugs that depress respiration. So we would expect neurological inpatients
would have relatively high rates of adverse events while hospitalized.
Now the American Academy of Neurology (AAN) has established
a set of quality measures for inpatient and emergency care for neurological
patients (Josephson
2017).
The AAN inpatient and emergency care quality measurement set
“focuses on brain death, urinary catheters, delirium, Guillain-Barré syndrome (GBS),
myasthenic crisis, status epilepticus, bacterial meningitis, advanced
directives, and goals of care.” We are happy to see a few of our favorite
topics appearing in the new measurement set (reduction of urinary catheters
used in neurologic patients, delirium risk factor screening and preventive
protocol, nonpharmacologic treatment of delirum). And we’re also happy to see
the braindeath documentation measure and immunosuppressive treatment of
Guillain-Barre Syndrome measure (since we co-authored New York State’s original
guideline on braindeath determination and co-authored a text on Guillain-Barre
Syndrome). Rounding out the quality measures are several measures regarding status
epilepticus, EEG, coma, bacterial meningitis, discussion and documentation of
advanced directives, and discussion and documentation of goals of care.
The accompanying editorial (Vespa 2017)
explains how the quality measures were selected and the challenges encountered.
It notes that they were selected not only for demonstrating how often
appropriate care is delivered but also for highlighting areas in which
opportunities to improve care are present. For example, they note that
documentation of braindeath determination is known to be suboptimal so it was
selected as a measure.
It should be noted that many other quality measures
involving neurological inpatients are captured in other data sets (eg. measures
regarding falls, pressure ulcers, and DVT prophylaxis are captured in multiple
data sets and quality measures for stroke care are also found in several data
sets).
References:
Josephson SA, Ferro J, Cohen A, et al. Quality improvement
in neurology: Inpatient and emergency care quality measure set: Executive
summary. Neurology 2017; 89: 730-735; published ahead of print July 21, 2017
http://www.neurology.org/content/89/7/730.extract?etoc
Vespa PM, Ferro J, Josephson SA. Inpatient quality metrics in
neurology: A grand challenge. Neurology 2017; 89: 646-649; published ahead of
print July 21, 2017
http://www.neurology.org/content/89/7/646.extract?etoc
Print “November
2017 Neurology Inpatient Quality Measures”
Print “November
2017 What's New in the Patient Safety World (full column)”
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2017 SCANSMART Program to Use CT Safely in Children”
Print “November
2017 Bad Combination: Gabapentin and Opioids”
Print “November
2017 Syringe Re-Use Surprisingly Common”
Print “November
2017 Neurology Inpatient Quality Measures”
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