A variety of
complications may occur in patients with acute stroke. Aspriation pneumonia,
UTI, decubiti, contractures, DVT and pulmonary embolism are some of the more
common complications. Because patients with stroke also share numerous risk
factors for coronary artery disease, they may also be susceptible to myocardial
ischemia and arrhythmias. But we also see some patients who unexpectedly die
suddenly after stroke without good explanation. Some have speculated on the
possible role of sleep apnea in such cases.
A new study (Aaronson
2012) assessed use of nocturnal pulse oximetry to screen for sleep apnea in
stroke patients in an acute rehabilitation setting. They performed both
nocturnal oximetry and polysomnography on 56 stroke patients and found a 46%
prevalence of sleep apnea syndrome in those patients. Patients with sleep apnea
were older, more likely to be male, and had higher BMI’s than those without
sleep apnea. But subtype of stroke, stroke location, and degree of disability
did not correlate with sleep apnea.
The oxygen
desaturation index (ODI) on nocturnal pulse oximetry did correlate very well
with the apnea-hypopnea index (AHI) on polysomnography. And the sensitivity,
specificity, and positive and negative predictive values of nocturnal oximetry
for sleep apnea were quite good. In fact, in a multiple regression model the
ODI was the sole predictor of sleep apnea. For an ODI cutoff of 15 or more the
sensitivity of nocturnal oximetry was 77%, specificity 100%, and positive
predictive value 100% for sleep apnea. A negative result lowered the chance of
sleep apnea to 17%.
Since
polysomnography may not be readily available or convenient in many settings
rendering care for stroke patients, nocturnal oximetry seems to be a reasonable
way of identifying patients with likely sleep apnea. Even if such patients are not
begun on treatments such as CPAP, knowing they likely have sleep apnea should
lead to avoidance of certain medications (opioids, sedative/hypnotics, etc.)
that may exacerbate sleep apnea. It might also have implications for
positioning of patients during sleep (since many sleep apnea patients do worse
when supine).
Obviously, more work needs to be done in determining best practices for handling sleep apnea in stroke patients. But this study certainly highlights the scope of the problem and should spur such further work.
References:
Aaronson JA, van
Bezeij T, van den Aardweg jg, et al. Diagnostic Accuracy of Nocturnal Oximetry
for Detection of Sleep Apnea Syndrome in Stroke Rehabilitation. Stroke 2012; first published on July
19 2012 as doi:10.1161/STROKEAHA.112.665414
http://stroke.ahajournals.org/content/early/2012/07/19/STROKEAHA.112.665414.abstract
Print “September
2012 Obstructive Sleep Apnea in Stroke Patients”
Estimates of rates
of adverse events in hospitals depend on the methodology used. Manual chart
reviews are cumbersome, time-consuming and labor-intense and grossly
underestimate actual rates of adverse events. Use of trigger tools may help the
process by identifying charts likely to have associated adverse events. The
IHI Global Trigger Tool methodology is “doable” with limited resources and
provides a more reliable comparison of adverse events over time. See our October
30, 2007 Patient Safety Tip of the Week “Using IHI's Global Trigger Tool”
and our April 15, 2008 Patient Safety Tip of the Week “Computerizing
Trigger Tools” for more details on how to use it.
Our May 2011 What’s New in the Patient Safety World column “Just How Frequent Are Hospital Medical Errors?” highlighted a study using IHI’s Global Trigger Tool to identify hospital adverse events (Classen 2011) that found that the rates of adverse events may be 10-fold higher than what was noted in the IOM report
Now a new study using a similar trigger tool assessed rates of adverse events in hospitalized pediatric patients in Canada (Matlow 2012). They used the Canadian Paediatric Trigger Tool, a validated tool similar to the IHI Global Trigger tool to identify charts for review in 8 academic pediatric medical centers and 14 community hospitals. The overall rate of adverse events was 9.2%. The overall rate of adverse events was almost 3 times higher in the academic centers but this was largely driven by a higher rate of non-preventable adverse events. Preventable adverse events occurred with roughly the same frequency in both settings. Surgery-related events predominated overall and were more common in the academic centers, whereas diagnostic errors were less frequent in academic centers.
The authors conclude that there are many opportunities to reduce harm affecting children in hospitals, particularly related to surgery, intensive care and diagnostic error.
References:
Classen D, Resar R, Griffin F, et al. ‘Global Trigger Tool’ Shows That Adverse Events In Hospitals May Be Ten Times Greater Than Previously Measured. Health Affairs 2011; 30(4): 581-589
http://content.healthaffairs.org/content/30/4/581.abstract
Matlow AG, Baker GR,
Flintoft V, et al. Adverse events among children in Canadian hospitals: the
Canadian Paediatric Adverse Events Study. CMAJ 2012; July 30, 2012 First
published July 30, 2012, doi: 10.1503/cmaj.112153
July 30, 2012
http://www.cmaj.ca/content/early/2012/07/30/cmaj.112153
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2012 Canadian Paediatric Adverse Events Study”
After a series of
articles with not-so-good conclusions regarding medication reconiciliation,
we’ve finally seen some good news. First, a recent large randomized clinical
trial (Kripalani
2012) showed that over 50% of
patients with cardiac conditions discharged from hospitals had one or more
clinically significant medication errors and that a health-literacy–sensitive,
pharmacist-delivered intervention did not reduce post-discharge medication
error rates. Then a recent systematic review of medication reconciliation
practices in hospitals (Mueller
2012) highlighted the relative paucity of high quality evidence supporting
best practices for medication reconciliation. They concluded that the best
evidence supports use of pharmacy staff in the medication reconciliation
process and targeting high-risk patients. But for most other approaches, there
is a relative paucity of evidence demonstrating desired outcomes.
But a new study from
Johns Hopkins (Feldman
2012) has more promising news using a nurse-pharmacist team to do
medication reconciliation. They found that a dedicated nurse interviewing the
patient and/or contacting the patient’s PCP or pharmacy or reviewing the EMR
was able to identify unintended discrepancies from the home medication list
compiled by the physician on admission in almost 50% of patients. The nurse
would then discuss those discrepancies with a consulting pharmacist and the
physician to come up with the best medication list. Such discrepancies were
slightly less common on discharge but those found on discharge had higher risk
of causing harm to the patient. They provided a cost analysis of the program
and concluded that it cost about $32 per patient or $114 to uncover one
potentially harmful discrepancy. Using a figure from the literature of $9300 to
manage each case with harmful events, they conclude that the program justifies
itself financially many times over.
An editorial
accompanying the Mueller review (Kaboli
2012) reinforces that targeted interventions are probably most
cost-effective. They advocate for
targeting highest-risk patients for medication reconciliation but note the need
to balance this against the need to provide safe medication practices for all
patients.
There is more to medication
reconciliation that just identifying what medications the patient is taking at
home. One field we commonly see missing on medication reconciliation forms is
“time last dose taken”. While that may be less relevant for drugs like daily
statins, it is very relevant for drugs like insulin, anticoagulants, or
cardiovascular medications that affect blood pressure or heart rate. Add to
that the nuances of various hospital pharmacy dispensing systems that relate
time of the order to time a medication may be given. For example, some
hospitals might dispense/administer their “once daily” medications every
morning at 8:00 AM. In such cases, a patient admitted at 8:30 AM may not get
his/her dose of that medication until 8:00 AM the following morning. In the old
days a physician would handwrite orders and given them to a nurse who would
often ask “do you want the patient to get a dose today?”. Nowdays, with CPOE
that step is often lost and there may be no warning on the CPOE system that
such medications won’t be given until the next morning.
References:
Feldman LS, Costa LL, Feroli ER, et al. Nurse-pharmacist collaboration on medication reconciliation prevents potential harm. J Hosp Med 2012; 7(5): 396-401
http://onlinelibrary.wiley.com/doi/10.1002/jhm.1929/abstract
Mueller SK, Sponsler KC, Kripalani S, Schnipper JL. Hospital-Based Medication Reconciliation PracticesA Systematic Review. Arch Intern Med. 2012; 172(14): 1057-1069
http://archinte.jamanetwork.com/article.aspx?articleid=1203516
Kaboli PJ, Fernandes O. Medication ReconciliationComment on “Hospital-Based Medication Reconciliation Practices”. Arch Intern Med. 2012; 172(14): 1069-1070
http://archinte.jamanetwork.com/article.aspx?articleid=1203520
Kripalani S, Roumie CL, Dalal AK, et al. Effect of a Pharmacist Intervention on Clinically Important Medication Errors After Hospital Discharge: A Randomized Trial
Ann Intern Med 2012; 157(1): 1-10
http://annals.org/article.aspx?articleid=1206684
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2012 Good News on Medication Reconciliation”
The Joint Commission
has just released Sentinel
Event Alert Issue 49: Safe use of opioids in hospitals. In their review of
sentinel events related to opioids 47% were due to wrong doses and 29% to
improper monitoring. They note that the risk of respiratory depression due to
opioids is likely greater than reported, that higher opioid doses are often
involved, and that there are various risk factors that predispose certain
patients to the respiratory depressant effects of opioids. We’ve outlined the
latter in our numerous articles on opioids and respiratory depression (see list
at end of today’s column) but the new alert provides a nice table of those risk
factors.
Recommendations
include:
·
Screening for
respiratory depression risk factors
·
Assess prior
history of use and abuse, tolerance or intolerance, etc.
·
Do full body
search for fentanyl patches or other opioid delivery devices
·
Use multimodal
treatment when possible to minimize use of opioids
·
Be very wary in
opioid-naïve patients; consider starting with low doses and titrating
·
Use pharmacists
or pain management staff when converting between drugs or switching mode of
delivery
·
Be particularly
careful during transitions of care or patient transport
·
Both pulse
oximetry and capnography monitoring should be continuous rather than
intermittent
·
Build red flags
into CPOE and e-prescribing systems (dose limits, verifications, etc.)
·
Use tall-man lettering
for look-alike/sound-alike (LASA) drugs
·
Use dose
conversion support systems to help with changes in drug or route of
administration
·
Use of PCA with
smart pump technology may be helpful
They have good
recommendations for staff and patient/family education on opioid use. They also
have good recommendations on various tools.
See also our
September 2012 What’s New in the Patient Safety World column “FDA
Warning on Codeine Use in Children Following Tonsillectomy”
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
And we think you’ll learn a lot from our prior articles
pertaining to long-acting and/or extended release preparations of opioids:
June 28, 2011 “Long-Acting
and Extended-Release Opioid Dangers”
September 13,
2011 “Do
You Use Fentanyl Transdermal Patches Safely?”
May 2012 “Another
Fentanyl Patch Warning from FDA”
July 24, 2012 “FDA
and Extended-Release/Long-Acting Opioids”
References:
The Joint
Commission. Sentinel Event Alert Issue 49: Safe use of opioids in hospitals.
August 8, 2012
http://www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf
Print “September
2012 Joint Commission Sentinel Event Alert on Opioids”
The FDA has just
issued a safety alert warning on use of codeine in children after tonsillectomy
and/or adenoidectomy for obstructive sleep apnea (FDA 2012). This is
both timely and very informative and contains some very important information
we had not been previously aware of (though many pediatricians may have known).
They issued the alert after reviewing reports in the literature of 3 deaths and one near-miss case of respiratory depression in young children (ages 2-5) following tonsillectomy and/or adenoidectomy for obstructive sleep apnea (Ciszkowski 2009, Kelly 2012). The most interesting facet is the data presented on unusual metabolism of codeine as a root cause. Ingested codeine is converted into morphine in the liver by cytochrome P450 2D6 (CYP2D6). It turns out there are genetic variations that cause some people to be “ultra-rapid metabolizers” which leads to higher concentrations of morphine earlier. Apparently all the children in the above reports were “ultra-rapid metabolizers”.
In the reported cases obstructive sleep apnea (OSA) was the reason for tonsillectomy and/or adenoidectomy. The potiential for a variety of opioids to cause adverse effects in patients with OSA is well known. Ciszkowski et al. point out that as many as a third of young children with obstructive sleep apnea remain symptomatic after adenotonsillectomy (Ciszkowski 2009).
The FDA alert estimates the number of “ultra-rapid metabolizers” as generally 1 to 7 per 100 people, but may be as high as 28 per 100 people in some ethnic groups (the FDA site has a table of these rates by ethnic group). The FDA recommendations for healthcare professionals are:
· If prescribing codeine-containing drugs, use the lowest effective dose for the shortest period of time on an as-needed basis
· Counsel parents and caregivers on how to recognize the signs of morphine toxicity, and advise them to stop giving the child codeine and to seek medical attention immediately if their child is exhibiting these signs.
· Consider prescribing alternative analgesics for children undergoing tonsillectomy and/or adenoidectomy for obstructive sleep apnea syndrome.
The FDA notes there are FDA-cleared tests are available for determining a patient’s CYP2D6 genotype.
The FDA is also investigating whether similar adverse events have been related to codeine use in children having other surgeries or other types of pain.
References:
FDA. FDA Drug Safety
Communication: Codeine use in certain children after tonsillectomy and/or
adenoidectomy may lead to rare, but life-threatening adverse events or death.
8/15/12
http://www.fda.gov/Drugs/DrugSafety/ucm313631.htm
Ciszkowski C, Madadi P, Phillips MS, Lauwers AE, Koren G. Codeine, ultrarapid-metabolism genotype, and postoperative death. N Engl J Med 2009; 361(8): 827-828
http://www.nejm.org/doi/full/10.1056/NEJMc0904266
Kelly LE, Rieder M, van den Anker J, Malkin B, Ross C, Neely MN, et al. More codeine fatalities after tonsillectomy in North American children. Pediatrics 2012; 129:5 e1343-e1347; published ahead of print April 9, 2012
Print “September
2012 FDA Warning on Codeine Use in Children Following Tonsillectomy”
Print “September
2012 What's New in the Patient Safety World (full column)”
Print “September
2012 Obstructive Sleep Apnea in Stroke Patients”
Print “September
2012 Canadian Paediatric Adverse Events Study”
Print “September
2012 Good News on Medication Reconciliation”
Print “September
2012 Joint Commission Sentinel Event Alert on Opioids”
Print “September
2012 FDA Warning on Codeine Use in Children Following Tonsillectomy
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