Intravenous milrinone in treatment of advanced congestive heart failure

Phosphodiesterase inhibitors such as milrinone can relieve symptoms and improve hemodynamics in patients with advanced congestive heart failure. We retrospectively evaluated the hemodynamic and clinical outcomes of long-term combination therapy with intravenous milrinone and oral beta-blockers in 65 patients with severe congestive heart failure (New York Heart Association class IV function and ejection fraction <25%) refractory to oral medical therapy. Fifty-one patients successfully began beta-blocker therapy while on intravenous milrinone. Oral medical therapy was maximized when possible. The mean duration of milrinone treatment in this combination-treatment group was 269 days (range, 14-1,026 days). Functional class improved from IV to II-III with milrinone therapy. Twenty-four such patients tolerated beta-blocker up-titration and were successfully weaned from milrinone. Sixteen patients (31%) died while receiving combination therapy; one died of sudden cardiac death (on treatment day 116); the other 15 died of progressive heart failure or other complications. Hospital admissions during the previous 6 months and admissions within 6 months after milrinone initiation stayed the same. Meanwhile, the total number of hospital days decreased from 450 to 380 (a 15.6% reduction), and the mean length of stay decreased by 1.4 days (a 14.7% reduction). We conclude that 1) milrinone plus beta-blocker combination therapy is an effective treatment for heart failure even with beta-blocker up-titration, 2) weaning from milrinone may be possible once medications are maximized, 3) patients' functional status improves on the combination regimen, and 4) treatment-related sudden death is relatively infrequent during the combination regimen.     

Drug-induced illness as a cause for admission to a community hospital

To assess the rate of occurrence of drug-induced illness as a cause for admission to the general medicine service of a community hospital, charts were reviewed retrospectively of all patients admitted to the service over two randomly selected one-month periods. Statistical analysis was performed on patients over and under the age of 65, and on iatrogenic and noniatrogenic admissions. Twenty-three of 244 patients (9.4%) were admitted with drug-induced illness. Patients with drug-induced illness had 5.7 medications as compared to 3.2 medications per patient admitted for other reasons (P less than .05). A single drug was responsible for 61% of all drug-induced illness admissions. Aspirin and other nonsteroidal anti-inflammatory agents were most often implicated. Eighteen of 155 elderly patients (11.7%) were admitted with drug-induced illness. These patients were on an average of 6.3 medications as compared with 3.8 medications per elderly patient admitted for other causes (P less than .005). Polypharmacy and a preponderantly elderly population may explain the substantial number of admissions caused by adverse drug reactions. Further research to assess the role of patient age and the number and type of medications involved in the event of drug-induced illness requires standardization of definition and diagnostic criteria.     

Iatrogenic renal disease

We studied iatrogenic problems in nephrology by classifying all patients for nephrology consultation into nine presenting syndromes and seven etiologic groups. One hundred (2.2%) of all admissions were seen in nephrology consultation. Acute renal failure was the most common presenting syndrome, accounting for 59% of the consultations. Forty-one of the 100 consultations (1% of all admissions) had a renewal syndrome of iatrogenic origin. Of these 41 patients, 38 had acute renal failure and three had fluid and electrolyte problems. Twenty of the 41 patients had drug-induced problems. Eighteen of these patients were dehydrated, and in three patients, acute renal failure occurred after surgery. Of the 20 patients with iatrogenic renal problems caused by drugs, seven problems were antibiotic related, five were due to diuretics, four were due to nonsteroidal anti-inflammatory drugs, three were due to angiotensin-converting enzyme inhibitors, and one was from the use of contrast medium. The 41 patients with iatrogenic-related renal disease were older than the other 59 patients (61.8 vs 49.3 years). Iatrogenic renal disease developed in 1% of all patients admitted to a tertiary care hospital, and 12% of these patients died. The most common renal syndrome is acute renal failure, most often caused by nephrotoxic drugs. The incidence can probably be decreased by better monitoring of body weight and fluid balance to prevent dehydration and by the avoidance of nephrotoxic drugs.     

A physician-based voluntary reporting system for adverse events and medical errors

OBJECTIVE: To create a voluntary reporting method for identifying adverse events (AEs) and potential adverse events (PAEs) among medical inpatients. DESIGN: Medical house officers asked their peers about obstacles to care, injuries or extended hospitalizations, and problems with medications that affected their patients. Two independent reviewers coded event narratives for adverse outcomes, responsible parties, preventability, and process problems. We corroborated house officers' reports with hospital incident reports and conducted a retrospective chart review. SETTING: The cardiac step-down, oncology, and medical intensive care units of an urban teaching hospital. INTERVENTION: Structured confidential interviews by postgraduate year-2 and -3 medical residents of interns during work rounds. MEASUREMENTS AND MAIN RESULTS: Respondents reported 88 events over 3 months. AEs occurred among 5 patients (0.5% of admissions) and PAEs among 48 patients (4.9% of admissions). Delayed diagnoses and treatments figured prominently among PAEs (54%). Clinicians were responsible for the greatest number of incidents (55%), followed by workers in the laboratory (11%), radiology (15%), and pharmacy (3%). Respondents identified a variety of problematic processes of care, including problems with diagnosis (16%), therapy (26%), and failure to provide clinical and support services (29%). We corroborated 84% of reported events in the medical record. Participants found voluntary peer reporting of medical errors unobtrusive and agreed that it could be implemented on a regular basis. CONCLUSIONS: A physician-based voluntary reporting system for medical errors is feasible and acceptable to front-line clinicians.     

Multidrug-Resistant Organism Infections in Patients with Left Ventricular Assist Devices

Left ventricular assist devices improve survival prospects in patients with end-stage heart failure; however, infection complicates up to 59% of implantation cases. How many of these infections are caused by multidrug-resistant organisms is unknown. We sought to identify the incidence, risk factors, and outcomes of multidrug-resistant organism infection in patients who have left ventricular assist devices.We retrospectively evaluated the incidence of multidrug-resistant organisms and the independent risk factors associated with them in 57 patients who had permanent left ventricular assist devices implanted at our institution from May 2007 through October 2011. Outcomes included death, transplantation, device explantation, number of subsequent hospital admissions, and number of subsequent admissions related to infection. Infections were categorized in accordance with criteria from the Infectious Diseases Council of the International Society for Heart and Lung Transplantation.Multidrug-resistant organism infections developed in 18 of 57 patients (31.6%)—a high incidence. We found 3 independent risk factors: therapeutic goal (destination therapy vs bridging), P=0.01; body mass index, P=0.04; and exposed velour at driveline exit sites, P=0.004. We found no significant differences in mortality, transplantation, or device explantation rates; however, there was a statistically significant increase in postimplantation hospital admissions in patients with multidrug-resistant organism infection. To our knowledge, this is the first report in the medical literature concerning multidrug-resistant organism infection in patients who have permanent left ventricular assist devices.     

Assessing the preventability of emergency hospital admissions. A method for evaluating the quality of medical care in a primary care facility

The quality of primary medical care was assessed by studying the events leading to 686 emergency admissions of patients from our hospital-based primary care practice. Independent physician reviewers determined that 59 (9 percent) of the admissions were potentially preventable; 40 were due to iatrogenic factors including inadequate follow-up and adverse drug reactions, 12 were due to lack of patient compliance, and seven were due to both iatrogenesis and noncompliance. Adverse drug reactions were the most common cause of iatrogenesis, and warfarin was the drug that most commonly caused an adverse reaction. Inadequate follow-up of abnormal physical findings, symptoms, and laboratory test results was also important. Patients with preventable admissions had more medical diagnoses (4.9 versus 4.1, p less than 0.01), were prescribed more medications (4.5 versus 3.7, p less than 0.01), and were older (66.5 years versus 60.2 years, p less than 0.01) than patients whose admissions were not preventable. It is concluded that a small percentage of emergency hospitalizations may be preventable and that systematic review of emergency hospitalizations may provide a means of measuring the quality of primary medical care.     

Das Delir im höheren Lebensalter

Delirium is a common, serious medical and often life-threatening condition in elderly in-patients. Delirium can develop primarily or secondarily related to other medical conditions and lead to hospital admission. The pathogenesis is still not fully known and is usually addressed as multifactorial. Alterations in neurotransmitters have a key role in this process. The incidence varies by setting up to 90%. Delirium is associated with increased short- and long-term mortality, iatrogenic complications, functional decline, and future development of cognitive impairment or dementia. Delirium is also associated with longer hospital stays, higher hospital and total health system costs, and an increasing rate of nursing home admissions. A structured diagnostic and therapeutic process is recommended. Delirium should become a quality indicator for hospital medicine; however, many research questions still exist.     

Evaluation of opioid induced nausea and vomiting in sickle cell disease

A common side effect of opioids is nausea and vomiting; however, the incidence in hospitalized patients receiving opioids for acute pain is unknown. We performed a retrospective study in adult patients with sickle cell disease admitted for an acute pain crisis during a six-month period to evaluate the incidence of nausea and vomiting and characterize the prescribing of antiemetics. Eligibility included normal hepatic and renal function. Thirty-four subjects with a total of 97 admissions were evaluated. As expected, opioids were prescribed during all admissions. Fifty percent of the subjects experienced nausea or vomiting during the study period and these same patients accounted for the majority of the admissions, 17 subjects with 71 admissions (Group I). Nausea was reported in 18 (25%) of these admissions and vomiting was reported in 24 (34%) of these admissions. The most common antiemetics prescribed were: prochlorperazine, metoclopramide, and promethazine and antiemetics were ordered during 22 (23%) separate admissions for all subjects included in the study. The clinical benefit of these medications is limited due to uneven documentation. In conclusion, many of our patients experienced nausea or vomiting with antiemetics infrequently prescribed on an as needed basis. This suggests a need for better approaches to manage nausea and vomiting in patients receiving opioids.     

Multicomponent Interventions Reduce High‐Risk Medications for Delirium in Hospitalized Older Adults

Delirium threatens the functional independence and cognitive capacity of patients. Medications, especially those with strong anticholinergic effects, have been implicated as a preventable cause of delirium. We evaluated the effect of multicomponent interventions aimed at reducing the use of 9 target medications in hospitalized older adults at risk of delirium. This continuous quality improvement program was undertaken at a tertiary care facility and 4 community hospitals in a hospital system. We included 21, 541 hospital admissions with patients aged 70 and older on acute care medical or surgical units from the preintervention (2012) period, and 27,764 from the postintervention (2015) period. Implemented interventions include formulary and policy changes, technology‐assisted medication review, age‐conditional order set modifications, best practice alerts, and education. The proportion of hospital admissions with individual's receiving at least 1 target medication declined from 45.6% to 31.3% (relative reduction (RR)=31.4%) from before to after the intervention, meaning that target medication exposure was avoided in approximately 4,000 older adults. The greatest effect was observed for zolpidem (11.2% to 5.3%, RR=52.6%) and diphenhydramine (12.9% to 7.1%, RR=45%). Furthermore, the mean number of doses administered during all hospital admissions was reduced for 7 of 9 medications. Multicomponent interventions implemented in our hospital system were effective at reducing exposure to target medications in hospitalized older adults at risk of delirium. These systematic changes applied throughout the medication use process are sustained today.     

Hospitalization due to adverse drug reactions and drug interactions before and after HAART.

OBJECTIVE: To characterize and compare the rates of adverse drug reactions (ADRs) and interactions on admission in two, one-year periods: pre-highly active antiretroviral therapy (HAART) (phase 1) and post-HAART (phase 2). DESIGN: Retrospective chart review. SETTING: University-affiliated tertiary care centre. POPULATION STUDIED: HIV-positive patients admitted to hospital. MAIN RESULTS: In phase 1, 436 of 517 admissions, and, in phase 2, 323 of 350 admissions were analyzed. Over 92% of patients were male, with a mean age of 38 years. Significant differences (P<0.05) in the mean length of stay (12.08 versus 10.02 days), the CD4 counts (99.25 versus 129.45) and the number of concurrent diseases (4.20 versus 3.63) were found between phase 1 and 2, respectively. The mean number of medications taken (5.52 versus 5.94) and the rates of hospitalization with ADRs (20.4% versus 21.4%) or interactions (2.5% versus 2.16%) were similar between the two phases. Antiretrovirals were more common in ADR admissions post-HAART (21.3% versus 36.2%), while antiparasitics, psychotherapeutics and antineoplastics were more common pre-HAART. Other classes of drugs involved in both phases were sulphonamides, narcotics, ganciclovir, foscarnet, antimycobacterials and antifungals. ADR causality was possible or probable in more than 80% of cases. Over 60% of ADRs were grades 3 to 4, and about 85% were either the main or contributing reason for admission. About 65% of patients had at least partial recovery at the time of discharge. In phases 1 and 2, 8.9% and 2.9% of admissions,respectively, with ADRs were fatal. CONCLUSIONS: Although hospitalizations with ADRs and interactions were similar in both phases, HAART therapy has had a significant impact on the incidence and nature of ADRs at St Michael's Hospital, Wellesley Central Site, Toronto, Ontario.     

Intravenous therapy team and peripheral venous catheter-associated complications. A prospective controlled study

A prospective controlled trial was conducted on four similar inpatient medical wards to test the hypothesis that a trained intravenous therapy (IVT) team would substantially reduce the incidence of peripheral intravenous (IV) catheter-related complications. We followed 863 IV catheters. The overall incidence of phlebitis in the ward staff-maintained IV catheters was 32% as compared with 15% for those maintained by the IVT team. The incidence of two more serious complications (cellulitis and suppurative phlebitis) was reduced tenfold from 2.1% to 0.2%. We conclude that an IVT team can substantially reduce the iatrogenic complications related to IV catheters.     

Audit of anticoagulant therapy and acute hospital admissions

We conducted an audit on the contribution of failure of control of anticoagulant therapy to acute hospital admissions. Over a period of 3 months there were 1480 acute admissions. One-hundred-and-twelve (7.6%) of these patients were on anticoagulant therapy. One-hundred-and-three of these 112 patients were evaluated, 74 patients had international normalized ratios (INRs) in the therapeutic range, of whom four (5.4%) bled from causes unlikely to be due directly to anticoagulant therapy. Twenty-nine patients were over-anticoagulated. Of these, 17 (59%) were admitted with bleeding symptoms, which may have been a consequence of high INR, while one had a very high INR but no bleeding. Eleven more patients were admitted for reasons unrelated to anticoagulant therapy but were found to have over-therapeutic INRs, which may have influenced their subsequent hospital management. The only clear difference between the bleeding and nonbleeding groups was age. Reasons for over-anticoagulation were poor patient compliance in 31%, influence of other medications in 17, congestive heart failure in 28%, and unknown in 24%. In conclusion, 22/1480 hospital admissions (1.5%) were due to warfarin complications and 16/21 bleeding patients had INRs > 4.5. These are admissions that could potentially be avoided with better anticoagulation control.     

The diseases we cause: Iatrogenic illness in a department of internal medicine

BACKGROUND: The aim of this study was to estimate the incidence, main causes, and risk factors of iatrogenic disease occurring in a department of internal medicine. METHODS: Over a 1-year period, physicians systematically filled out a 2-page questionnaire for all patients admitted to the ward. A database was created and the data were statistically analyzed. Patients undergoing immunosuppressive, chemo-, or radiation therapy were excluded. Missing data were completed by reviewing the patients' charts. The patients were then divided into two groups: those with and those without iatrogenic disease. The groups were compared using several parameters including gender, age, social features, days of hospitalization, associated illness, functional status, medical impression, prognosis, associated renal or liver function impairment, drugs taken daily, and outcome. In the group with iatrogenic disease, the type, severity, and predictability were also analyzed. RESULTS: Of the 879 patients admitted to the ward, 445 completed questionnaires and were included in the study. A total of 102 patients (22.9%) developed 121 iatrogenic events. Forty-four patients (43.1%) were admitted for iatrogenic illness, 10 (9.8%) developed life-threatening events, and in 3 (6.8%) it was the cause of death. Fifty-eight patients (56.8%) registered 77 episodes of iatrogenic disease during their hospital stay, 20 (19.6%) developed life-threatening events, and 9 (11.7%) died, 4 (5.2%) of an iatrogenic cause (nosocomial infections). Significant differences were found in 20 out of 26 parameters studied (p<0.005 for all cases; 95% confidence interval). Eighteen percent of all iatrogenic disease was severe, 61.9% predictable, 54.5% avoidable, and 59% drug-related, 80% of which was due to side effects or adverse reactions. Infection and metabolic and electrolyte disorders were the most frequent effects. CONCLUSIONS: It is possible to identify risk factors for iatrogenic events. Chronically ill elderly inpatients are the main target of iatrogenic events.     

Esophageal ulceration complicating doxycycline therapy

AIM: To report present state of iatrogenic drug-induced esophageal injury (DIEI) induced by medications in a private clinic. METHODS: Iatrogenic drug-induced esophageal injury (DIEI) induced by medications has been more frequently reported. In a private clinic we encountered 36 cases of esophageal ulcerations complicating doxycycline therapy in a mainly younger Saudi population (median age 29 years). RESULTS: The most frequent presenting symptoms were odynophagia, retrosternal burning pain and dysphagia (94 %, 75 % and 56 %, respectively). The diagnosis was according to medical history and confirmed by endoscopy in all patients. Beside withdrawal of doxycycline, when feasible, all patients were treated with a proton-pump inhibitor (PPI) and a prokinetic. Thirty patients who reported to the clinic after treatment were improved within 1-7 (median 1.7) days. CONCLUSION: Esophageal ulceration has to be suspected in younger patients with odynophagia, retrosternal burning pain and/or dysphagia during the treatment with doxycycline.     

Seasonal Fluctuations in Acute Upper Gastrointestinal Bleeding: Lack of Effect of Nonsteroidal Anti-inflammatory Drugs

The seasonal pattern of community-based acute bleeding from the upper gastrointestinal (UGI) tract was studied prospectively in 1988-1991. Out of 3343 emergency admissions to the Departments of General Surgery, 321 (9.6%) were due to acute UGI bleeding. There was a significant monthly variation in the total number of admissions, as well as in the number of admissions due to acute UGI bleeding (p < 0.0001). However, there was no correlation between the two. Significant seasonal fluctuations were noted both in the absolute number of admissions due to acute UGI bleeding and in the percentage of UGI bleeding admissions of the total number of admissions to the Departments of General Surgery (p = 0.0002). During summer (July through September), the incidence declined significantly to a nadir of 5.5% of total number of admissions in July. The seasonal fluctuation correlated closely with the incidence of duodenal ulcer, but not with that of gastric ulcer. The seasonal pattern was consistent both in patients who had used aspirin or other nonsteroidal anti-inflammatory drugs as well as in those who had not.     

Sins of omission

BACKGROUND: Little is known about the relative incidence of serious errors of omission versus errors of commission. OBJECTIVE: To identify the most common substantive medical errors identified by medical record review. DESIGN: Retrospective cohort study. SETTING: Twelve Veterans Affairs health care systems in 2 regions. PARTICIPANTS: Stratified random sample of 621 patients receiving care over a 2-year period. MAIN OUTCOME MEASURE: Classification of reported quality problems. METHODS: Trained physicians reviewed the full inpatient and outpatient record and described quality problems, which were then classified as errors of omission versus commission. RESULTS: Eighty-two percent of patients had at least 1 error reported over a 13-month period. The average number of errors reported per case was 4.7 (95% confidence intervals [CI]: 4.4, 5.0). Overall, 95.7% (95% CI: 94.9%, 96.4%) of errors were identified as being problems with underuse. Inadequate care for people with chronic illnesses was particularly common. Among errors of omission, obtaining insufficient information from histories and physicals (25.3%), inadequacies in diagnostic testing (33.9%), and patients not receiving needed medications (20.7%) were all common. Out of the 2,917 errors identified, only 27 were rated as being highly serious, and 26 (96%) of these were errors of omission. CONCLUSIONS: While preventing iatrogenic injury resulting from medical errors is a critically important part of quality improvement, we found that the overwhelming majority of substantive medical errors identifiable from the medical record were related to people getting too little medical care, especially for those with chronic medical conditions.     

Polypharmacy - we make it worse! A cross-sectional study from an acute admissions unit

Although polypharmacy is a major problem in the elderly, very few data have been published from Australasia. We retrospectively audited 68% of elderly patients admitted acutely to our medical unit (n= 424, mean age 80.3 ± 8 years) during a 30-day period (September, 2008). We found that long-term medications increased during hospital stay from 6.6 ± 4 to 7.7 ± 4 (P < 0.001). Adverse drug reactions were responsible for 24 admissions (5.7%). Polypharmacy is made worse by acute admission to hospital.     

Longitudinal prescribing patterns in a nursing home population.

OBJECTIVE: This study documents the patients characteristics associated with prescribed medications on entry to a nursing home and the change in prescribing patterns after 3 months. DESIGN: One-year admission cohort. SETTING: Three university-affiliated community nursing homes in Albuquerque, NM. PATIENTS: All new admissions (n = 81) to a University geriatrics team, covering intermediate and skilled levels of care during 1 year (July 1, 1988-July 1, 1989). METHODS: Outcome measures were scheduled and as-needed (PRN) medications prescribed at entry and 3 months. Data collected at entry included patient demographics, activities of daily living index, mental status score, and medical diagnoses. RESULTS: Older persons were prescribed fewer scheduled medications than younger ones, and women fewer than men. There was a positive association between the number of diagnoses and the number of scheduled medications (r = 0.25, P = 0.02). No associations were found between medications prescribed and mental status or functional level. There were no associations between as-needed (PRN) medications and any of the variables studied. Overall, there was a significant increase in the average total number of medications prescribed between admission (4.7) and 3 months (6.2). This was due to an increase in the number of PRN medications from 1.3 at admission to 3.0 at 3 months (P less than 0.001). CONCLUSIONS: Measuring medications at consistent points in a person's nursing home stay may be more informative than using cross-sectional sampling. Future studies on medications in nursing home populations should distinguish between PRN and scheduled medications because medication prescribing patterns may be different in these categories.