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 “”).
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:
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
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.
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.
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
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”
March 10, 2015 “FDA Warning Label on Insulin Pens: Is It Enough?”
April 14, 2015 “Using Insulin Safely in the Hospital”
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
One & Only Campaign.
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 “”), 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).
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
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
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