Rob Shulman

Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit

IntroductionThe study aimed to compare the impact of computerised physician order entry (CPOE) without decision support with hand-written prescribing (HWP) on the frequency, type and outcome of medication errors (MEs) in the intensive care unit.MethodsDetails of MEs were collected before, and at several time points after, the change from HWP to CPOE. The study was conducted in a London teaching hospitals 22-bedded general ICU. The sampling periods were 28 weeks before and 2, 10, 25 and 37 weeks after introduction of CPOE. The unit pharmacist prospectively recorded details of MEs and the total number of drugs prescribed daily during the data collection periods, during the course of his normal chart review.ResultsThe total proportion of MEs was significantly lower with CPOE (117 errors from 2429 prescriptions, 4.8%) than with HWP (69 errors from 1036 prescriptions, 6.7%) (p < 0.04). The proportion of errors reduced with time following the introduction of CPOE (p < 0.001). Two errors with CPOE led to patient harm requiring an increase in length of stay and, if administered, three prescriptions with CPOE could potentially have led to permanent harm or death. Differences in the types of error between systems were noted. There was a reduction in major/moderate patient outcomes with CPOE when non-intercepted and intercepted errors were combined (p = 0.01). The mean baseline APACHE II score did not differ significantly between the HWP and the CPOE periods (19.4 versus 20.0, respectively, p = 0.71).ConclusionIntroduction of CPOE was associated with a reduction in the proportion of MEs and an improvement in the overall patient outcome score (if intercepted errors were included). Moderate and major errors, however, remain a significant concern with CPOE.

H1N1 pneumonitis treated with intravenous zanamivir

On July 8, 2009, a 22-year-old woman, neutropenic after chemotherapy for Hodgkin’s disease, was referred to ICU with 3 days’ (d) increasing dyspnoea, bilateral chest in fi ltrates, and laboratory-confi rmed pandemic H1N1 2009 infl uenza virus infection not responding to oseltamivir 75 mg twice daily and broad-spectrum antimicrobials (mero penem, teicoplanin, and caspofungin). No other organisms were detected from blood or respiratory tract. Deterioration necessitated invasive ventilation from ICU d 3 (fi gure). She remained in single organ failure requiring high inspired oxygen, protective lung ventilation (tidal volumes ≤6–8 mL/kg), and neutral fl uid balance. Hydro cortisone was given (d 3–6), then gradually reduced and discontinued (d 13). Neutropenia recovered by d 6, although lymphopenia remained (webappendix). High level H1N1 RNA was detected in bronchoalveolar lavage (BAL) on d 10, despite 6 d oseltamivir given nasogastrically; in view of high volume gastric aspirates, this was replaced by nebulised zanamivir (d 6–13). Treatment escalation on d 13–16 delivered neither clinical nor virological response (fi gure). On d 16, intravenous zanamivir 600 mg twice daily (provided by GlaxoSmithKline, Brentford, Middlesex) was started as unlicensed antiviral monotherapy; agreement for use was granted by the Hospital Formulary Committee and next of kin. Methylprednisolone was also started. Our patient’s condition improved within 48 h, with a decrease in BAL viral load on d 21. She was extubated on d 21 and discharged to the ward on d 24. Antiviral and steroid treatment were stopped on d 26 and d 28, respectively. Since ICU discharge she remains stable. Of four nasopharyngeal swabs taken post-ICU, the third, taken on d 10 post-ICU, showed H1N1 RNA Ct of 24, although a repeat sample taken the next day was negative. In view of her immunosuppressed state and ongoing lymphopenia, inhaled zanamivir was started as a precaution, although her clinical status remained unchanged. Deaths due to pandemic H1N1 are primarily related to severe respiratory failure. Our patient did not respond to exten sive antiviral treatment and 2 weeks’ mechanical ventilation. RT-PCR detects viral RNA rather than infectious virus, but is used to semi-quantitatively assess replication. The small diff erence in Ct between d 10 and 16 implied continued high-level replication. Eff ective treat ment depends on adequate enteral absorption (oseltamivir) and an uninhibited access to the infected respira tory tissue (zanamivir). In view of high volume gastric aspirates, we used nebulised zanamivir. Since her infl amed, atelectatic lungs were probably im peding adequate drug absorption, and clinical improve ment was not forth coming, we used intravenous (un licensed) zanamivir. High dosing achieves eff ective respira tory epithelial concentrations and is well-tolerated. Our pa tient recovered with no side-eff ects. Despite in herent sampling inconsistencies, the change in BAL Ct from 23 to 30 after 5 d treatment indicates an approximate 128-fold fall in viral load. Persisting high-level H1N1 replication may drive ongoing lung infl ammation and fi brosis (im plied by our patient’s poor lung compliance). We reasoned that synergism could exist between intra venous zanamivir and high-dose corticosteroids, al though this approach may be considered controversial and is not recom mended in treatment guide lines. However, con trolled trials are lacking and a rationale does exist for the use of corticosteroids in ARDS. Although this is a single case report and direct cause and eff ect cannot be confi rmed, the im prove ment in clinical status following intravenous zanamivir encourages prompt further investigation, both alone and in com bination with high-dose methyl pred nisolone.

Keeping the Circuit Open: Lessons from the Lab

Background: Hemofiltration circuits generally require anticoagulation to prevent the membrane from clotting. Understanding the mechanisms involved in premature clotting of the filtration circuit is useful to optimize anticoagulation and maintain filter patency. Aims: To discuss research performed at our institution which throws light on the causes of premature clotting of the hemofilter, and to highlight our approach to anticoagulation. Discussion: Premature clotting of the circuit is related to low baseline levels of antithrombin III (AT-III), heparin co-factor II and tissue factor pathway inhibitor. Clotting is preceded by a precipitous rise in thrombin-antithrombin complexes, suggesting thrombin generation. Our standard anticoagulant is unfractionated heparin, where the primary mode of action is potentiation of endogenous AT-III. However, AT-III levels are diminished in sepsis and other causes of systemic inflammation. To supplement or prevent consumption of AT-III we use fresh frozen plasma or aprotinin (as cheaper alternatives to AT-III) in situations where filter life span is limited and mechanical obstruction has been excluded. Anticoagulation can be managed in heparin-induced thrombocytopenic patients with danaparoid, prostaglandins and/or predilution.

Adsorption of insulin onto infusion sets used in adult intensive care unit and neonatal care settings

INTRODUCTION Insulin adsorption onto infusion equipment may affect glycaemic control. METHODS The change in insulin concentration during delivery through tubing employed for adult ICU and neonatal patients was determined using continuous flow UV analysis. RESULTS Insulin adsorption depended on tubing composition, dimensions and flow rate, being highest for neonatal polyvinylchloride tubing at low flow rates. CONCLUSION In continuous insulin therapy, we should consider the nature of the infusion set and flow rate.

Pharmacist's review and outcomes: Treatment-enhancing contributions tallied, evaluated, and documented (PROTECTED-UK)

PURPOSE The purpose was to describe clinical pharmacist interventions across a range of critical care units (CCUs) throughout the United Kingdom, to identify CCU medication error rate and prescription optimization, and to identify the type and impact of each intervention in the prevention of harm and improvement of patient therapy. MATERIALS AND METHODS A prospective observational study was undertaken in 21 UK CCUs from November 5 to 18, 2012. A data collection web portal was designed where the specialist critical care pharmacist reported all interventions at their site. Each intervention was classified as medication error, optimization, or consult. In addition, a clinical impact scale was used to code the interventions. Interventions were scored as low impact, moderate impact, high impact, and life saving. The final coding was moderated by blinded independent multidisciplinary trialists. RESULTS A total of 20517 prescriptions were reviewed with 3294 interventions recorded during the weekdays. This resulted in an overall intervention rate of 16.1%: 6.8% were classified as medication errors, 8.3% optimizations, and 1.0% consults. The interventions were classified as low impact (34.0%), moderate impact (46.7%), and high impact (19.3%); and 1 case was life saving. Almost three quarters of interventions were to optimize the effectiveness of and improve safety of pharmacotherapy. CONCLUSIONS This observational study demonstrated that both medication error resolution and pharmacist-led optimization rates were substantial. Almost 1 in 6 prescriptions required an intervention from the clinical pharmacist. The error rate was slightly lower than an earlier UK prescribing error study (EQUIP). Two thirds of the interventions were of moderate to high impact.

Observational study of current use of selective decontamination of the digestive tract in UK Critical Care units

BACKGROUND Evidence supporting selective decontamination of the digestive tract (SDD) is reasonably strong. We set out to determine use in UK critical care units and to compare patient outcomes between units that do and those that do not use SDD. METHODS A total of 250 UK general critical care units were surveyed. Case mix, outcomes, and lengths of stay for admissions to SDD units (with and without an i.v. component) and non-SDD units were compared using data from the Intensive Care National Audit & Research Centre Case Mix Programme database. RESULTS A response was received from all the 250 critical care units surveyed. Of these, 13 (5.2%) reported using SDD on some or all admissions, and of these, 3 reported using an i.v. component. Data on 284,690 admissions (April 2008-March 2011) from units reporting to the ICNARC Case Mix Programme (CMP) were included in the analyses. Admissions to SDD (n=196) and non-SDD (n=9) units were a similar case mix with similar infection rates and average lengths of stay in the unit and hospital. There was no difference in risk-adjusted unit or hospital mortality. The rate of unit-acquired infections in blood was significantly lower in SDD units using an i.v. component. CONCLUSIONS Use of SDD in UK critical care is very low. The rate of unit-acquired infections in blood was significantly lower in SDD units using an i.v. component, but did not translate into a difference in acute hospital mortality or length of stay. There is a need to better understand the barriers to adoption of SDD into clinical practice and such work is underway.

Medication issues experienced by patients and carers after discharge from the intensive care unit

PURPOSE Medication-related problems (MRPs) frequently occur at the interfaces of care settings. We examined this further because little has been published about MRPs experienced by patients/carers after discharge from the intensive care unit (ICU). METHODS AND MATERIALS Medication history data were collected before, during, and after ICU admission and by face-to-face semistructured interviews with 21 patients and 13 carers attending the ICU Follow-up Clinic (FC) of our 35-bed adult ICU. RESULTS A total of 122 drugs were prescribed regularly before ICU admission, 168 on ICU discharge, 132 at hospital discharge, and 128 at the FC. Medication-related problems were identified with hypnotics/anxiolytics, antidepressants, proton pump inhibitors, and analgesics. Good follow-up was observed in all 4 cases where the antidysrhythmic agent amiodarone was initiated on ICU. Patients/carers described 20 cases of difficulty in obtaining appropriate and timely supplies and 19 of insufficient information. CONCLUSIONS These results show that our incidence of MRPs after ICU discharge was encouragingly infrequent, in which we attribute it to targeted medicine reconciliation and the availability of our FC. However, MRPs were perceived to stem from inadequate communication at the interfaces of care and the lack of opportunity for patients/carers to obtain relevant information. We recommend that FC should focus on MRPs during their consultation and that further research in this area should be performed to examine our observations further.

An analysis of medicine costs of adult patients on a critical care unit

PURPOSE To evaluate the costs of medicines used to treat critically ill patients in an intensive care environment and to correlate this with severity of illness and mortality. MATERIALS AND METHODS The study was conducted at a London Teaching Hospital Critical Care Unit. Data were collected for patients who were either discharged or died during September 2011 and stayed longer than 48 hours. The drug cost was related to 150 drugs that were then related to patients acuity and outcome. RESULTS The median daily drug cost of the 85 patients was £26. The highest cost patients in the 85th percentile had significantly higher daily drug costs (median, £403) and higher scores for patient acuity. Patients with hematologic malignancy had a median daily drug cost (£561) more than 20 times higher than those without. A regression analysis based on patients diversity explained 93% of the variance in the daily drug cost. CONCLUSIONS Although the median daily drug cost for an adult critically ill patient was low, this cost significantly escalated with patient acuity and hematologic malignancy. A reference method has been designed for an in-depth evaluation of daily drug cost that could be used to compare expenditure in other units.

Impact of the introduction of a specialist critical care pharmacist on the level of pharmaceutical care provided to the critical care unit

To evaluate the impact of a dedicated specialist critical care pharmacist service on patient care at a UK critical care unit (CCU).

Management of a mixed overdose of calcium channel blockers, β-blockers and statins

We describe a case of extreme mixed overdose of calcium channel blockers, β-blockers and statins. The patient was successfully treated with aggressive resuscitation including cardiac pacing and multiorgan support, glucagon and high-dose insulin for toxicity related to calcium channel blockade and β-blockade, and ubiquinone for treating severe presumed statin-induced rhabdomyolysis and muscle weakness.