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

Life-threatening bronchospasm induced by an angiotensin-converting enzyme inhibitor in a chronically ventilated patient: Diagnostic pitfalls and literature review

Cough- and asthma-like symptoms are common adverse reactions to angiotensin-converting enzyme inhibitors (ACEi). However, attributing these symptoms to the use of ACEi might be masked by clinical confounders. We report a 68-year-old female residing in a long-term acute-care facility for patients requiring prolonged invasive mechanical ventilation treated for years with ACEi. Daily reversible bouts of life-threatening severe bronchospasm gradually developed over 6 weeks and abruptly resolved following the cessation of ACEi treatment. The late appearance of bronchospasm and the unique clinical setup of chronic invasive ventilation in a patient with smoking-related chronic obstructive lung disease are among the principal confounders that delay the identification of the causative association between ACEi and respiratory compromise. Chronic positive pressure ventilation may also conceal small airway reactivity and obstruction, similar to auto-positive end-expiratory pressure (auto-PEEP). Conceivably, angiotensin receptor blockers should be preferred over ACEi in such patients.

The Effectiveness of Transition Interventions to Support Older Patients From Hospital to Home: A Systematic Scoping Review

BACKGROUND

Interventions supporting older adults' transition from hospital to home can address geriatric needs. Yet this evidence base is fragmented. This review describes transitional interventions that provide pre- and post-discharge support for older adults and evaluates their implementation and effectiveness in improving health and well-being.

METHOD

Articles were included if they examined the extent to which transitional interventions were effective in improving health and well-being outcomes and reducing hospital readmission rates among older adults.

RESULTS

Twenty studies met the inclusion criteria. Four types of interventions were identified: education-based (10/20); goal-oriented (4/20); exercise (4/20); and social support interventions (2/20). Education and goal-oriented interventions were effective in improving health and well-being outcomes. The impact of interventions on mitigating hospital readmissions was inconclusive. Only five studies examined implementation.

DISCUSSION

Older adults transitioning from hospital to home would benefit from tailored education and goal-oriented interventions that promote their capacity for self-care.

Adverse Drug Reactions in Hospitalized Patients: Results of the FORWARD (Facilitation of Reporting in Hospital Ward) Study

Background: Adverse drug reactions (ADRs) are an important public health problem, representing a major cause of morbidity and mortality. However, several countries have no recent studies available. Since 2014, a prospective active pharmacovigilance project, aimed to improve ADRs monitoring in hospital wards (FORWARD) was performed in Sicily. This study, as part of FORWARD project, was aimed to describe ADRs occurred during the hospital stay in Internal Medicine wards. ADRs related to hospital admission, characteristics and preventability of ADRs were also evaluated.

Methods: Demographic, clinical, and pharmacological data on patients admitted to six wards of Internal Medicine, from 2014 to 2015, were collected by trained, qualified monitors, who screened all medical records. The rate of ADRs occurred during hospital stay and those leading to hospitalization were analyzed. A descriptive analysis of the reactions, suspected drugs, and associated factors was performed according to the setting analyzed.

Results: During the study period, 4,802 admissions were recorded; in 3.2% of them ADRs occurred during hospital stay while in 6.2%, admission was due to ADRs. The duration of hospital stay was longer in patients who experienced ADRs during hospitalization, compared to patients without ADRs [median days 12 (Q1–Q3: 8–17) vs. 9 (6–13)]; p < 0.001). Females [OR1.39 (95% CI 1.03–1.93)] and patients taking ≥ 4 drugs [OR1.46 (95% CI 1.06–2.03)] were more likely to experience ADRs during hospital stay, as well as to be admitted because of ADRs [female: OR1.75 (95% CI 1.37–2.24); ≥ 4 drugs: OR2.14 (95% CI 1.67–2.74)]. The most frequent ADRs occurred during hospital stay were cutaneous (26.8%), general (13.4%), vascular (13.4%), and cardiac (11.5%) disorders and the drug classes mainly involved were anti-bacterials (38.2%) and antithrombotic agents (21.7%). ADRs were serious in 44.6% and probably preventable in 69.4%. Gastrointestinal (27.7%), hematological (26.5%), metabolic (18.1%), and nervous (16.1%) disorders were the main ADRs cause of hospitalization, primarily due to antithrombotic agents (39.0%) RAS-inhibitors (13.9%), NSAIDs (11.9%), and diuretics (9.0%). Only 12.9% of them was not preventable.

Conclusion: Adverse drug reactions occurred during hospitalization or contributing to admission to Internal Medicine wards were considerable and most of them were preventable. Females and patients taking many medications were more likely to present ADRs both during hospital stay or as cause of admission.

Hospitalisation in an emergency department short-stay unit compared to an internal medicine department is associated with fewer complications in older patients - an observational study

BACKGROUND

Older patients are at particular risk of experiencing adverse events during hospitalisation.

OBJECTIVE

To compare the frequencies and types of adverse events during hospitalisation in older persons acutely admitted to either an Emergency Department Short-stay Unit (SSU) or an Internal Medicine Department (IMD).

METHODS

Observational study evaluating adverse events during hospitalisation in non-emergent, age-matched, internal medicine patients ≥75 years, acutely admitted to either the SSU or the IMD at Holbaek Hospital, Denmark, from January to August, 2014. Medical records were reviewed by independent assessors to detect adverse events according to predefined criteria. The primary outcome was the proportion of patients with an adverse event during and within 30 days after hospitalisation. Secondary outcomes included 90-day mortality, subtypes of adverse events, and timing of adverse events. Adjusted analyses were conducted to correct for potential confounders.

RESULTS

Four-hundred-fifty patients, 225 patients in each group, were included. Adverse events were found in 67 (30%) patients in the SSU-group and 90 (40%) patients in the IMD group (Odds Ratio (OR) 0.64 (95% Confidence Interval (95% CI) 0.43-0.94, p = 0.02). The result was unchanged in an analysis adjusted for age, Charlson Comorbidity score, and sex. We found no significant difference in 90-day mortality (OR 0.75, 95% CI 0.41-1.38, p = 0.36). The most common adverse events were transfer during hospitalisation, unplanned readmission, and nosocomial infection.

CONCLUSIONS

Adverse events of hospitalisation were significantly less common in older patients acutely admitted to an Emergency Department Short-stay Unit as compared to admission to an Internal Medicine Department.

A decade of adverse drug events in Portuguese hospitals: space-time clustering and spatial variation in temporal trends

Background

The aim of this study is to identify the distribution by municipalities of adverse drug events (ADE) in Portugal, including adverse drug reactions (ADR) and accidental poisoning by drugs (AP), on municipality/years ADE rate clustering. Also we identify areas with different trends in time.

Methods

We used a national dataset of public hospital discharges in Continental Portugal from 2004 to 2013. Events were identified based on codes: from E930 to E949.9 (ADR) and from E850 to E858.9 (AP). Space-time clustering and spatial variation in temporal trends methods were applied in three different time-periods: globally, by year and grouped in 2 classes (periods of 5 years).

Results

A total of 9,320,076 patients were discharged within this period, with 133,688 patients (1.46%) having at least one ADE, 4% of them related with AP. Critical space-time identified clusters (p < 0.001) were the municipalities from Lisbon metropolitan area and Centro region area. The global rate increased at a 7.8% mean annual percentage change, with high space-time heterogeneity and variation in time trends clusters (p < 0.001). For whole period, 2004–2013, all clusters presented increasing trends. However when analyzed by period of 5 years we identified two clusters with decreasing trends in time in 2004–2008.

Conclusion

The impact of ADE is huge, with widely variations within country and in time, and represents an increasing challenge. Future research using individual and contextual risk factors are urgently needed to understand this spatiotemporal variability in order to promote local tailored and updated actions of prevention.

Which adverse events are related to health care during hospitalization in elderly inpatients?

BACKGROUND

Adverse events result in longer hospital stays and increase costs and mortality. We aimed to assess incidence of adverse events occurring during hospitalization in a post-emergency unit and to describe their characteristics.

METHODS

All adverse events occurring in patients during their hospitalization in a post-emergency unit in a French university hospital (20 beds) were systematically and consecutively recorded from September 2009 to February 2011. Patients with adverse events were compared to up to three control patients, matched for date of admission +/- age in the same unit.

RESULTS

We identified 56 patients with 64 adverse events, giving an incidence of 3.0/100 patients admitted/year. Fifty-one adverse events were drug-related. Patients had a median age of 82.5 years with a male/female ratio of 1/1.4. They presented a median Charlson score of 1 and the median number of medications was 6. The drugs most frequently involved in drug-related events were nervous system drugs (47%) and anti-infectives (22%). In multivariate analysis, a Charlson score ≥ 2 was associated with the occurrence of adverse events (OR 0.4; 95% CI [0.21 - 0.80]).

CONCLUSIONS

Systematic recording showed that adverse events were not rare in a post-emergency unit. Patients with comorbid conditions were less likely to present an adverse event, possibly because of greater precautions taken by the medical team.

Medical adverse events in elderly hospitalized patients: a prospective study

OBJECTIVES

To determine the frequency of medical adverse events in elderly patients admitted to an acute care geriatric unit, the predictive factors of occurrence, and the correlation between adverse events and hospital mortality rates.

METHODS

This prospective study included 171 admissions of patients aged 60 years and older in the acute care geriatric unit in a teaching hospital in Brazil between 2007 and 2008. The following variables were assessed at admission: the patient age, gender, number of prescription drugs, geriatric syndromes (e.g., immobility, postural instability, dementia, depression, delirium, and incontinence), comorbidities, functional status (evaluated with the Katz Index of Independence in Activities of Daily Living), and severity of illness (evaluated with the Simplified Acute Physiology Score Il). The incidence of delirium, infection, mortality, and the prescription of potentially inappropriate medications (based on the Beers criteria) were assessed during hospitalization. An observer who was uninvolved in patient care reported the adverse events.

RESULTS

The mean age of the sample was 78.12 years. A total of 187 medical adverse events occurred in 94 admissions (55%). The predictors of medical adverse events were undetermined. Compared with the patients with no adverse events, the patients with medical adverse events had a significantly longer hospital stay (21.41 ± 15.08 days versus 10.91 ± 7.21 days) and a higher mortality rate (39 deaths [41.5%] versus 17 deaths [22.1%]). Mortality was significantly predicted by the Simplified Acute Physiology Score II score (odds ratio [OR] = 1.13, confidence interval [CI] 95%, 1.07 to 1.20), the Katz score (OR=1.47, CI 95%, 1.18 to 1.83), and medical adverse events (OR = 3.59, CI 95%, 1.55 to 8.30).

CONCLUSION

Medical adverse events should be monitored in every elderly hospitalized patient because there is no risk profile for susceptible patients, and the consequences of adverse events are serious, sometimes leading to longer hospital stays or even death.