Dominique Wouters

Current practices and barriers impairing physicians' and nurses' adherence to analgo-sedation recommendations in the intensive care unit - A national survey

IntroductionAppropriate management of analgo-sedation in the intensive care unit (ICU) is associated with improved patient outcomes. Our objectives were: a) to describe utilization of analgo-sedation regimens and strategies (assessment using scales, protocolized analgo-sedation and daily sedation interruption (DSI)) and b) to describe and compare perceptions challenging utilization of these strategies, amongst physicians and nurses.MethodsIn the 101 adult ICUs in Belgium, we surveyed all physicians and a sample of seven nurses per ICU. A multidisciplinary team designed a survey tool based on a previous qualitative study and a literature review. The latter was available in paper (for nurses essentially) and web based (for physicians). Topics addressed included: practices, perceptions regarding recommended strategies and demographics. Pre-testing involved respondents’ debriefings and test re-test reliability. Four reminders were sent.ResultsResponse rate was 60% (898/1,491 participants) representing 94% (95/101) of all hospitals. Protocols were available to 31% of respondents. Validated scales to monitor pain in patients unable to self-report and to monitor sedation were available to 11% and 75% of respondents, respectively. Frequency of use of sedation scales varied (never to hourly). More physicians than nurses agreed with statements reporting benefits of sedation scales, including: increased autonomy for nurses (82% versus 68%, P <0.001), enhancement of their role (84% versus 66%, P <0.001), aid in monitoring administration of sedatives (83% versus 68%, P <0.001), and cost control (54% versus 29%, P <0.001). DSI was used in less than 25% of patients for 75% of respondents. More nurses than physicians indicated DSI is contra-indicated in hemodynamic instability (66% versus 53%, P <0.001) and complicated weaning from mechanical ventilation (47% versus 29%, P <0.001). Conversely, more physicians than nurses indicated contra-indications including: seizures (56% versus 40%, P <0.001) and refractory intracranial hypertension (90% versus 83%, P <0.001). More nurses than physicians agreed with statements reporting DSI impairs patient comfort (60% versus 37%, P <0.001) and increases complications such as self-extubation (82% versus 69%, P <0.001).ConclusionsCurrent analgo-sedation practices leave room for improvement. Physicians and nurses meet different challenges in using appropriate analgo-sedation strategies. Implementational interventions must be tailored according to profession.

Risk scores and geriatric profile: can they really help us in anticoagulation decision making among older patients suffering from atrial fibrillation?

Objectives Anticoagulation for the prevention of cardio-embolism is most frequently indicated but largely underused in frail older patients with atrial fibrillation (AF). This study aimed at identifying characteristics associated with anticoagulation underuse. Methods A cross-sectional study of consecutive geriatric patients aged ≥75 years, with AF and clear anticoagulation indication (CHADS2 [Congestive heart failure, Hypertension, Age >75, Diabetes mellitus, and prior Stroke or transient ischemic attack] ≥2) upon hospital admission. All patients benefited from a comprehensive geriatric assessment. Their risks of stroke and bleeding were predicted using CHADS2 and HEMORR2HAGES (Hepatic or renal disease, Ethanol abuse, Malignancy, Older (age >75 years), Reduced platelet count or function, Rebleed risk, Hypertension (uncontrolled), Anemia, Genetic factors, Excessive fall risk, and Stroke) scores, respectively. Results Anticoagulation underuse was observed in 384 (50%) of 773 geriatric patients with AF (median age 85 years; female 57%, cognitive disorder 33%, nursing home 20%). No geriatric characteristic was found to be associated with anticoagulation underuse. Conversely, anticoagulation underuse was markedly increased in the patients treated with aspirin (odds ratio [OR] [95% confidence interval]: 5.3 [3.8; 7.5]). Other independent predictors of anticoagulation underuse were ethanol abuse (OR: 4.0 [1.4; 13.3]) and age ≥90 years (OR: 2.0 [1.2; 3.4]). Anticoagulation underuse was not inferior in patients with a lower bleeding risk and/or a higher stroke risk and underuse was surprisingly not inferior either in the AF patients who had previously had a stroke. Conclusion Half of this geriatric population did not receive any anticoagulation despite a clear indication, regardless of their individual bleeding or stroke risks. Aspirin use is the main characteristic associated with anticoagulation underuse.

INT-007 Detection of look-alike intravenous drugs – formulary considerations

Background Look-alike packaging (LAP) designates similarity in labelling and packaging between two drugs. LAPs increase the risk of confusion while drug dispensing by technicians and pharmacists and drug administration by nurses, consequently leading to medication errors. No method exists to prospectively identify pairs of drugs and characteristics increasing confusion. Objectives We propose a prospective identification method of LAPs in our hospital formulary, specifically on intravenous drugs. Our main objective was to validate our method of risk assessment. Other objectives were to evaluate the burden of LAP’s, to determine possible differences in results between different healthcare professionals (HCPs) and to identify risk factors of confusion inherent to drugs. Method We selected 64 vials and 105 ampoules having a significant turnover in the pharmacy, allowing evaluation of risk for 2016 pairs of vials and 5460 pairs of ampoules. All pairs (primary packaging) were systematically observed by six HCPs independently (two nurses, two technicians and two pharmacists). If risk was identified by at least four HCPs, the pair was qualified as at “risk of confusion” (PairRC) and at “high risk of confusion” (PairHRC) if all HCPs perceived a risk. Inter-rater reliability was calculated (Cohen kappa test). Results Inter-rater reliability varied from modest to good. A fifth of the vials and half the ampoules were identified at risk. No marked difference in number of pairs at risk was present amongst different professions, even though different pairs were identified by nurses. Risk factors of confusion are engravement and same manufacturer. Conclusion Methods to identify risk of confusion prospectively should be implemented to propose preventive measures in order to reduce medication errors. Strategies for improvement may include over labelling, stockage in different places, educational strategies. No conflict of interest.