Sandra Verelst

Incidence and preventability of adverse events requiring intensive care admission: a systematic review.

RATIONALE, AIMS AND OBJECTIVES Adverse events are unintended patient injuries or complications that arise from health care management resulting in death, disability or prolonged hospital stay. Adverse events that require critical care are a considerable financial burden to the health care system, but also their global impact on patients and society is probably underestimated. The objectives of this systematic review were to synthesize the best available evidence regarding the estimates of the incidence and preventability of adverse events that necessitate intensive care admission, to determine the type and consequences [mortality, length of intensive care unit (ICU) stay and costs] of these adverse events. METHODS MEDLINE (from 1966 to present), EMBASE (from 1974 to present) and CENTRAL (version 1-2010) were searched for studies reporting on unplanned admissions on ICUs. Several other sources were searched for additional studies. Only quantitative studies that used chart review for the detection of adverse events requiring intensive care admission were considered for eligibility. For the purposes of this systematic review, ICUs were defined as specialized hospital facilities which provide continuous monitoring and intensive care for acutely ill patients. Studies that were published in the English, Dutch, German, French or Spanish language were eligible for inclusion. Two reviewers independently extracted data and assessed the methodological quality of the included studies. RESULTS A total of 27 studies were reviewed. Meta-analysis of the data was not appropriate because of methodological and statistical heterogeneity between studies; therefore, results are presented in a descriptive way. The percentage of surgical and medical adverse events that required ICU admission ranged from 1.1% to 37.2%. ICU readmissions varied from 0% to 18.3%. Preventability of the adverse events varied from 17% to 76.5%. Preventable adverse events are further synthesized by type of event. Consequences of the adverse events included a mean length of ICU stay that ranged from 1.5 days to 10.4 days for the patients first stay in ICU and mortality percentages between 0% and 58%. CONCLUSIONS Adverse events are an important reason for (re)admission to the ICU and a considerable proportion of these are preventable. It was not possible to estimate an overall incidence and preventability rate of these events as we found considerable heterogeneity. To decrease adverse events that necessitate ICU admission, several systems are recommended such as early detection of patients with clinical instability on general wards and the implementation of rapid response teams. Step-down or intermediate care units could be a useful strategy for patients who require monitoring to avoid ICU readmissions. However, the effectiveness of such systems needs to be investigated.

Ethylene glycol poisoning presenting with a falsely elevated lactate level

Early diagnosis of ethylene glycol poisoning is crucial in order to prevent morbidity and mortality. However, diagnosis can sometimes be delayed because of the false elevation of lactate in some chemistry analyzers as a result of the interference of glycolate, a metabolite of ethylene glycol. We present a case of ethylene glycol poisoning presenting with a falsely elevated lactate level on a blood gas analyzer in the emergency department. Given the fact that nowadays there is a marked increase in use of point-of-care analyzers, one should be aware of possible false readings since they use different methods of measuring compared with clinical chemistry analyzers. On the other hand, measuring a “lactate gap” using two different technologies, only one of which is sensitive to glycolate, could be a clinically efficient way to make the diagnosis of advanced ethylene glycol poisoning in the emergency department or other critical care setting.

Emergency Department Visits Due to Alcohol Intoxication: Characteristics of Patients and Impact on the Emergency Room

AIMS The aim of the study was to describe the epidemiology, management and cost of emergency department (ED) visits due to alcohol intoxication. METHODS A retrospective review of medical records of all episodes of alcohol intoxication was made, excepting those where another diagnosis such as trauma or psychiatric illness was primary, in patients older than 16 years, who presented to the ED of a large university hospital in Belgium over a 12-month period from 1 January 2009. RESULTS A total of 635 such patients accounted for 1.2% of all ED visits; 429 were males and 48.3% were aged between 41 and 60 years; 63.8% of the patients had a history of alcohol use disorder and 60.3% had a history of psychiatric disorder; 74.3% of the patients received some form of medical treatment and 62% were seen by a psychiatrist. Of the total, 57.5% of the patients were admitted to the ED observation ward, with a mean length of stay of 8.4 h. The estimated total cost was €318 838.25, with an average of €541.32 per patient. CONCLUSION Alcohol intoxication leads to a financial burden on the community. In addition to imposing physical, social and psychological stress on the community, the often agitated or aggressive patient imposes stress on ED staff. Close surveillance of trends in alcohol abuse is warranted, and the ED should consider implementing a questionnaire method of screening for alcohol abuse.

Deliberate self-poisoning: characteristics of patients and impact on the emergency department of a large university hospital

Study objective The epidemiology, management and cost of emergency department (ED) visits for deliberate self-poisoning (DSP) are described. Methods In a retrospective study, the medical records of all DSP patients older than 16 years, who presented to the ED from 1 January 2009 to 31 December 2009, were reviewed. Results 312 episodes of DSP were included, accounting for 0.6% of all ED visits. 190 patients were women, with a female to male ratio of 1.56:1. Mean patient age was 37 years. More than 60% (n=190) of DSP patients were <40 years of age. Most patients presented to the ED between 18:00 and 23:00. A single drug was ingested in 39% (n=121) of patients. Alcohol was co-ingested by 36% of patients who were mostly middle-aged men. Of the overdoses, 50.8% were due to benzodiazepines, 23.2% were due to antidepressants and 16.4% were due to antipsychotics. Two-thirds of patients were treated with oral activated charcoal and 89% were seen by a psychiatrist. Nearly 90% of patients were admitted to the ED observation ward, with a mean length of stay of 16.7 h. The estimated total cost was €;266 134.89, with an average of €;872.57 per patient. Conclusion Self-poisoning cases in Belgium are grossly similar to those in other Western countries. Supportive treatment alone should be considered in the majority of patients presenting with oral drug overdose. Overall, DSP leads to a significant financial burden on the community.

SHORT-TERM UNSCHEDULED RETURN VISITS OF ADULT PATIENTS TO THE EMERGENCY DEPARTMENT

BACKGROUND Emergency department (ED) crowding is a major international concern that affects patients and providers. STUDY OBJECTIVE We describe the characteristics of patients who had an unscheduled related return visit to the ED and investigate its relation to ED crowding. METHODS Retrospective medical record review of all unscheduled related ED return visits by patients older than 16 years of age over a 1-year period. The top quartile of ED occupancy rates was defined as ED crowding. RESULTS Eight hundred thirty-seven patients (1.9%) made an unscheduled related return visit. Length of stay (LOS) at the ED for the index visit and the LOS for the return visit (5 h, 54 min vs. 6 h, 51 min) were significantly different, as were the percent admitted (11.6% vs. 46.1%). Of these patients, 85.1% and 12.0% returned due to persistence or a wrong initial diagnosis, of their initial illness, respectively, and 2.9% returned due to an adverse event related to the treatment initially received. Patients presented the least frequently with an alcohol-related complaint during the index visit (480 patients), but they had the highest number of unscheduled return visits (45 patients; 9.4%). Unscheduled related return visits were not associated with ED crowding. CONCLUSION Return visits impose additional pressure on the ED, because return patients have a significantly longer LOS at the ED. However, the rate of unscheduled return visits and ED crowding was not related. Because this parameter serves as an essential quality assurance tool, we can assume that the studied hospital scores well on this particular parameter.

Knowing what to expect, forecasting monthly emergency department visits: A time-series analysis

OBJECTIVE To evaluate an automatic forecasting algorithm in order to predict the number of monthly emergency department (ED) visits one year ahead. METHODS We collected retrospective data of the number of monthly visiting patients for a 6-year period (2005-2011) from 4 Belgian Hospitals. We used an automated exponential smoothing approach to predict monthly visits during the year 2011 based on the first 5 years of the dataset. Several in- and post-sample forecasting accuracy measures were calculated. RESULTS The automatic forecasting algorithm was able to predict monthly visits with a mean absolute percentage error ranging from 2.64% to 4.8%, indicating an accurate prediction. The mean absolute scaled error ranged from 0.53 to 0.68 indicating that, on average, the forecast was better compared with in-sample one-step forecast from the naïve method. CONCLUSION The applied automated exponential smoothing approach provided useful predictions of the number of monthly visits a year in advance.

Intravenous lipid emulsion for intentional Chloroquine poisoning

To the Editor:Intravenous lipid emulsion (ILE) has successfully been used in local anesthetic toxicity and in poisonings with several other lipophilic drugs.1 There is evidence supporting the use o...

Validation of Hospital Administrative Dataset for adverse event screening

Objective To assess whether the Belgian Hospital Discharge Dataset (B-HDDS) is a valid source for the detection of adverse events in acute hospitals. Design, setting and participants Retrospective review of 1515 patient records in eight acute Belgian hospitals for the year 2005. Main outcome measures Predictive value of the B-HDDS and medical record reviews and degree of correspondence between the B-HDDS and medical record reviews for five indicators: pressure ulcer, postoperative pulmonary embolism or deep vein thrombosis, postoperative sepsis, ventilator-associated pneumonia and postoperative wound infection. Results Postoperative wound infection received the highest positive predictive value (62.3%), whereas postoperative sepsis and ventilator-associated pneumonia were rated as only 44.2% and 29.9% respectively. Excluding present on admission from the screening substantially decreased the positive predictive value of pressure ulcer from 74.5% to 54.3%, as pressure ulcers present on admission were responsible for more B-HDDS-medical record mismatches than any other indicator. Over half (56.8%) of false-positive cases for postoperative sepsis were due to a lack of specificity of the ICD-9-CM code, whereas in 58.6% of false-positive cases for ventilator-associated pneumonia, clinical criteria appeared to be too stringent. Conclusions The B-HDDS has the potential to accurately detect some but not all adverse events. Adding a code ‘present on admission’ and improving the ICD-9-CM codes might already partially improve the correspondence between the B-HDDS and the medical record review.

DRUG-RELATED ADMISSIONS DUE TO INTERACTION WITH AN OLD DRUG, LITHIUM

Abstract Lithium is one of the oldest psychotropic drugs with a well-known narrow therapeutic range and the drugs that interact with lithium elimination are well established. However, patients are still admitted to the emergency department with lithium toxicity due to often overlooked interactions with concomitant drugs. We report on two patients, admitted to the emergency department, with lithium toxicity. One patient presented with aphasia and ataxia, showing moderate toxicity. The other was referred due to coma, illustrating severe lithium toxicity. In both cases, a non-steroidal anti-inflammatory drug was the underlying cause. We highlight the mechanism of this drug-drug interaction and underline the need for thoughtful use of other medications in patients taking lithium. Special attention has to be paid for the non-steroidal anti-inflammatory drugs due to the low threshold of prescribing them for the control of acute pain and its availability as free over-the-counter drugs.

The number of patients simultaneously present at the emergency department as an indicator of unsafe waiting times: A receiver operated curve-based evaluation

BACKGROUND Emergency department (ED) crowding and prolonged waiting times have been associated with adverse consequences towards quality and patient safety. OBJECTIVE This study investigates whether the number of patients simultaneously present at the ED might be an indicator of unsafe waiting and at what threshold hospital-wide measures to improve patient outflow could be justified. METHODS Data were retrospectively collected during a 1-year period; all ED patients aged ≥16 years, and triaged as ESI-1 or ESI-2 were eligible for inclusion. The number of patients simultaneously present was used as occupancy rate. Waiting time was considered unsafe if it was longer than 10 min for ESI-1 patients, or longer than 30 min for ESI-2 patients. Differences in waiting time and occupancy between patients with safe and unsafe waiting times were analysed using the Mann-Whitney U test. The ability of the occupancy rate to discriminate unsafe waiting times was analysed using a receiver operating characteristic curve. RESULTS The overall median waiting time was 5 min (IQR=4-8) for ESI-1, and 12 min (IQR=6-24) for ESI-2 patients. Unsafe waiting times occurred in 16.0% of ESI-1 patients (median waiting time=17 min, IQR=13-23), and in 18.9% of ESI-2 patients (median waiting time=48 min, IQR=37-68). The occupancy rate was a weak indicator for unsafe waiting times in ESI-1 patients (AUC=0.625, 95%CI 0.537-0.713) but a fair indicator for unsafe waiting times in ESI-2 patients (AUC=0.740, 95%CI 0.727-0.753) for which the threshold to predict unsafe waiting times with 90% sensitivity was 51 patients. CONCLUSION The number of patients simultaneously present is a moderate indicator of unsafe waiting times. Future initiatives to improve safe waiting times should not focus solely on occupancy, and expand their focus towards other factors affecting waiting time.