P061: Preventable adverse drug events in Canadian emergency departments

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, cause or contribute to 2 million emergency department (ED) visits in Canada each year. Our objective was to determine the proportion of preventable ADEs by event type, severity, drug and drug class, and describe associated factors. Methods: We reviewed the charts of ADE patients enrolled in 1 of 3 prospective studies conducted in 3 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate causal associations between the drug regimens and patient presentations. After completion of the prospective study, a research pharmacist and physician independently reviewed the charts of all ADE patients, abstracted data using an electronic form and applied 3 preventability algorithms. The main outcome was a probably or definitely preventable ADE defined as avoidable by adhering to best medical practice, appropriate monitoring, taking a history of prior ADEs, compliance with recommended therapy, and avoidance of errors. Reviewers discussed discordant ratings until reaching consensus. We used kappa scores to evaluate between rater agreement, and investigated risk factors for preventability using logistic regression. Sample size was based on enrolment into the parent studies. Results: We reviewed the charts of 670 patients diagnosed with 725 ADEs. We excluded 44 patients with incomplete assessments. The inter-rater agreement in categorizing ADEs as preventable was 0.51 (95%CI 0.42-0.59). We deemed 61% (95%CI 57-65%) of ADEs preventable. Of preventable events, 30% were due to non-adherence, 24% to adverse reactions, and 15% to an excessive dose, and 29% required hospital admission. Among preventable events, 8% were due to warfarin, 5% hydrochlorothiazide, 3% acetylsalicylic acid, and 3% insulin. On multivariate analysis, mental health diagnoses were associated with preventable ADEs (OR 2.1, 95%CI 1.3-3.3, p=0.002). Conclusion: In this large multi-centre cohort, preventable events made up the majority of ADEs, and utilized substantial hospital resources. Strategies to reduce ED visits due to ADEs should target improving adherence behavior, and developing interventions for patients with mental health diagnoses and on high-risk medications.

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LO91: Repeat exposures to culprit drugs contribute to adverse drug events in emergency department patients

CJEM ◽

10.1017/cem.2017.153 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S59

Author(s):

C.M. Hohl ◽

S. Woo ◽

A. Cragg ◽

D. Villanyi ◽

M.E. Wickham ◽

...

Keyword(s):

Emergency Department ◽

Adverse Drug Events ◽

Tertiary Care ◽

Inappropriate Drug ◽

Drug Classes ◽

Culprit Drug ◽

Drug Regimens ◽

Systematic Selection ◽

Emergency Department Patients ◽

Repeat Events

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, cause or contribute to 2 million annual emergency department (ED) visits in Canada. Australian data indicate that 27% of ADEs requiring admission are events caused by re-exposure to drugs that previously caused harm. Our objective was to estimate the frequency of repeat ADEs. Methods: We reviewed the charts of ADE patients who had been enrolled in 1 of 3 prospective studies conducted in 2 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate the causal association between the drug regimens and patient presentations. After completion of the parent studies, a research pharmacist and a physician independently reviewed the charts of ADE patients, abstracted data using electronic forms, and searched that hospital’s records for previously recorded ADEs. The main outcome was a repeat ADE, defined as a same or same-class drug re-exposure, or repeat inappropriate drug withdrawal, causing a same or similar presentation as a prior ADE. Sample size was based on enrolment into the parent studies. Results: We reviewed the charts of 614 ED patients diagnosed with 655 ADEs. Of these, 20% (133/665, 95%CI 17.0-23.0%) were repeat events. Most repeat ADEs were moderate (61%) or severe (32%) in nature, and 33% (95%CI 25.1-41.1%) required hospital admission. The most commonly implicated drugs were warfarin (10%), hydrochlorothiazide (4%) and insulin (4%), and the most commonly implicated drug classes were antithrombotics (17%), psychotropics (12%) and analgesics (9%). Repeat ADEs commonly required clinical monitoring (59%), additional medications to treat the ADE (50%) and follow-up lab testing (35%). Overall, 61% (95%CI 51.3-70.7%) of culprit drug re-exposures were deemed potentially or definitely inappropriate. Conclusion: Inappropriate re-exposures to previously harmful medications cause a substantial number of recurrent ADEs, and may represent an ideal target for prevention. We were unable to search for repeat ADEs in the records of other hospitals that our patients may have visited, and could not detect ADEs that were not documented in the medical record. As a result, we likely underestimated the frequency of repeat ADEs.

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LO92: Factors contributing to the development of adverse drug events treated in emergency departments

CJEM ◽

10.1017/cem.2017.154 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S59-S60 ◽

Cited By ~ 3

Author(s):

S. Woo ◽

A. Cragg ◽

M.E. Wickham ◽

C.R. Ackerley ◽

D. Villanyi ◽

...

Keyword(s):

Adverse Drug Events ◽

Treatment Guidelines ◽

Tertiary Care ◽

Patient Counseling ◽

Contributing Factors ◽

Recommended Treatment ◽

Drug Regimens ◽

System Factors ◽

Systematic Selection

Introduction: Adverse drug events (ADEs), unintended and harmful events associated with medications, commonly cause or contribute to emergency department (ED) presentations. Understanding provider, patient and system factors that contribute to their development may assist in developing effective preventative strategies. Our objective was to identify factors that contributed to the development of ADEs that caused ED presentations. Methods: We reviewed the charts of ADE patients enrolled in 1 of 3 prospective studies conducted in 3 tertiary care and 1 urban community ED. In the parent studies, researchers enrolled patients by applying a systematic selection algorithm to minimize selection bias, and physicians and pharmacists evaluated patients prospectively to evaluate the causal associations between the drug regimens and patient presentations. Subsequently, a research pharmacist and physician independently reviewed the charts of ADE patients from these cohorts, abstracting data using electronic forms. Reviewers recorded patient, provider and system factors that contributed to the development of ADEs. The main outcome was the presence of at least one contributing factor in the development of an ADE. We used descriptive statistics with appropriate measures of variance. The sample size was determined by enrolment into the primary studies. Results: We reviewed the charts of 670 patients diagnosed with 725 ADEs. We identified ≥1 contributing factors in 62% (95%CI 58-65%) of ADEs. Multiple contributing factors were present in 17% of ADEs (95%CI 13-20%). The most common contributing factors were inadequate patient counseling or instructions about medication use (15%), insufficient laboratory monitoring or follow-up of monitoring tests (12%), lack of staff education (7%), lack of provider adherence with recommended treatment guidelines (7%), and delayed or inadequate clinical reassessment after a medication change (6%). Provider errors in drug administration contributed to 0.3% of ADEs (95%CI 0.0-0.7). Conclusion: Contributing factors were identified for most ADEs. They were often related to inadequate counseling and follow-up, and were rarely the result of errors. Further research is required to understand how communication of medication instructions can be improved. Investments in technologies to reduce provider errors may not significantly reduce the numbers of ADE patients presenting to EDs.

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A multicenter study of short-term changes in mental health emergency services use during lockdown in Kitchener-Waterloo, Ontario during the COVID-19 pandemic

BMC Public Health ◽

10.1186/s12889-021-11807-4 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Christopher Dainton ◽

Simon Donato-Woodger ◽

Charlene H. Chu

Keyword(s):

Mental Health ◽

Emergency Services ◽

Suicide Attempts ◽

Mental Health Crisis ◽

Short Term ◽

Health Crisis ◽

Police Responses ◽

Ed Visits ◽

Mental Health Diagnoses ◽

Services Use

Abstract Background The COVID-19 pandemic and subsequent lockdown measures have led to increasing mental health concerns in the general population. We aimed to assess the short-term impact of the pandemic lockdown on mental health emergency services use in the Kitchener-Waterloo region of Ontario, Canada. Methods We conducted an observational study during the 6-month period between March 5 and September 5, 2020 using National Ambulatory Care Reporting System metadata from mental health visits to three regional Emergency Departments (ED); mental health and substance related police calls; and calls to a regional mental health crisis telephone line, comparing volumes during the pandemic lockdown with the same period in 2019. Quasi-Poisson regressions were used to determine significant differences between numbers of each visit or call type during the lockdown period versus the previous year. Significant changes in ED visits, mental health diagnoses, police responses, and calls to the crisis line from March 5 to September 5, 2020 were examined using changepoint analyses. Results Involuntary admissions, substance related visits, mood related visits, situational crisis visits, and self-harm related mental health visits to the EDs were significantly reduced during the lockdown period compared to the year before. Psychosis-related and alcohol-related visits were not significantly reduced. Among police calls, suicide attempts were significantly decreased during the period of lockdown, but intoxication, assault, and domestic disputes were not significantly different. Mental health crisis telephone calls were significantly decreased during the lockdown period. There was a significant increase in weekly mental health diagnoses starting in the week of July 12 – July 18. There was a significant increase in crisis calls starting in the week of May 31 – June 6, the same week that many guidelines, such as gathering restrictions, were eased. There was a significant increase in weekly police responses starting in the week of June 14 – June 20. Conclusions Contrary to our hypothesis, the decrease in most types of mental health ED visits, mental health and substance-related police calls, and mental health crisis calls largely mirrored the overall decline in emergency services usage during the lockdown period. This finding is unexpected in the context of increased attention to acutely deteriorating mental health during the COVID-19 pandemic.

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Characteristics of frequent users of the emergency department with chronic pain

CJEM ◽

10.1017/cem.2019.464 ◽

2020 ◽

Vol 22 (3) ◽

pp. 350-358

Author(s):

Yaadwinder Shergill ◽

Danielle Rice ◽

Catherine Smyth ◽

Steve Tremblay ◽

Jennifer Nelli ◽

...

Keyword(s):

Mental Health ◽

Emergency Department ◽

Chronic Pain ◽

Abdominal Pain ◽

High Frequency ◽

Tertiary Care ◽

Chronic Abdominal Pain ◽

Primary Concern ◽

Physical And Mental Health ◽

Ed Visits

ABSTRACTObjectivesTo identify the proportion of high-frequency users of the emergency department (ED) who have chronic pain.MethodsWe reviewed medical records of adult patients with ≥ 12 visits to a tertiary-care, academic hospital ED in Canada in 2012-2013. We collected the following demographics: 1) patient age and sex; 2) visit details – number of ED visits, inpatient admissions, length of inpatient admissions, diagnosis, and primary location of pain; 3) current and past substance abuse, mental health and medical conditions. Charts were reviewed independently by two reviewers. ED visits were classified as either “chronic pain” or “not chronic pain” related.ResultsWe analyzed 4,646 visits for 247 patients, mean age was 47.2 years (standard deviation = 17.8), and 50.2% were female. This chart review study found 38% of high-frequency users presented with chronic pain to the ED and that women were overrepresented in this group (64.5%). All high-frequency users presented with co-morbidities and/or mental health concerns. High-frequency users with chronic pain had more ED visits than those without and 52.7% were prescribed an opioid. Chronic abdominal pain was the primary concern for 54.8% of high-frequency users presenting with chronic pain.ConclusionsChronic pain, specifically chronic abdominal pain, is a significant driver of ED visits among patients who frequently use the ED. Interventions to support high-frequency users with chronic pain that take into account the complexity of patient's physical and mental health needs will likely achieve better clinical outcomes and reduce ED utilization.

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A multicenter study of short-term changes in mental health emergency services use during lockdown in Kitchener-Waterloo, Ontario during the COVID-19 pandemic

10.21203/rs.3.rs-294465/v2 ◽

2021 ◽

Author(s):

Christopher Dainton ◽

Simon Donato-Woodger ◽

Charlene H. Chu

Keyword(s):

Mental Health ◽

Emergency Services ◽

Suicide Attempts ◽

Mental Health Crisis ◽

Short Term ◽

Health Crisis ◽

Police Responses ◽

Ed Visits ◽

Mental Health Diagnoses ◽

Services Use

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P014: An investigation to determine if being roomed next to a psychiatric patient affects patient satisfaction and perception of care in those not being evaluated for a psychiatric complaint

CJEM ◽

10.1017/cem.2016.190 ◽

2016 ◽

Vol 18 (S1) ◽

pp. S82-S83

Author(s):

F.A. Blais

Keyword(s):

Mental Health ◽

Patient Satisfaction ◽

Psychiatric Patient ◽

Psychiatric Patients ◽

Care Center ◽

Tertiary Care ◽

P Value ◽

Convenience Sample ◽

Ed Visits ◽

Perception Of Care

Introduction: Nearly 12 million emergency department (ED) visits in the USA annually are related to a mental health and/or substance abuse condition. This is equivalent to 1 out of every 8 ED visits or 12.5 percent of all ED visits annually. States cut $5 billion in mental health services from 2009 to 2012. In the same period, the country eliminated at least 4,500 public psychiatric hospital beds. This has led to an increase in psychiatric boarding. Boarding consumes scarce ED resources and prolongs the amount of time that all patients must spend waiting for services. The aim of this study is to determine if being roomed next to a psychiatric patient affects patient satisfaction and perception of care. Methods: A survey consisting of 15 patient satisfaction questions was distributed to patients over a period of three months in the ED at a tertiary care center with >125,000 visits a year. Patients included were English-speaking adults (18 years or older) with an Emergency Severity Index of 3-5. Responses were analyzed with a chi-square across 2 groups with p-value of 0.05 considered as significant. Results: A convenience sample of 78 surveys was obtained. 40 surveys were completed by those roomed next to a patient with a psychiatric complaint and 38 surveys were completed by patients not roomed next to a patient being seen for a psychiatric complaint. For every satisfaction question asked, the patients placed away from mental health encounters gave significantly higher ratings than the patients roomed near psychiatric patients. Patients roomed next to psychiatric patients had a statistically significant decrease in satisfaction in nursing attentiveness, nursing promptness in responding to the call bell, attentiveness of the physician team, and of the overall encounter itself. All values were significant with all but one p-value being <0.01.There was no difference between the 2 groups with respect to gender, age range, reason for visit or wait time. Conclusion: This study suggests that patients being roomed next to a patient with a psychiatric complaint had significantly decreased patient satisfaction.

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