Prehospital Medication Research Articles

A newly developed, easy-to-use prehospital drug-derived score compared with three conventional scores: A prospective multicenter study.

The use of medications by emergency medical services (EMS) is increasing. Conventional scores are time-consuming and therefore difficult to use in an emergency setting. For early decision-making, an easy-to-use score based on the medications administered by the EMS may have prognostic value. The primary objective of this study was to develop the prehospital drug-derived score (PDDS) for 2-day mortality. A prospective, multicenter, ambulance-based cohort study was conducted in adults with undifferentiated acute diseases treated by EMS and transferred to the emergency department. Demographic data, prehospital diagnosis data, prehospital medication and variables for the calculation of the National Early Warning Score 2 (NEWS2), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) were collected. The PDDS was developed and validated, establishing three levels of risk of 2-day mortality. The predictive capability of each score was determined by the area under the curve of the receiver operating characteristic curve (AUROC) and compared using the Delong's test (p-value). A total of 6401 patients were included. The PDDS included age and the use of norepinephrine, analgesics, neuromuscular blocking agents, diuretics, antihypertensive agents, tranexamic acid, and bicarbonate. The AUROC of PDDS was .86 (95% CI: .816-.903) versus NEWS2 .866 (95% CI: .822-.911), p = .828; versus REMS .885 (95% CI: .845-.924), p = .311; versus RAPS .886 (95% CI: .846-.926), p = .335, respectively. The newly developed easy-to-use prehospital drug-derived PDDS score has an excellent predictive value of early mortality. The PDDS score was comparable to the conventional risk scores and therefore might serve as an alternative score in the prehospital emergency setting.

Design of a Mixed-Reality Application to Reduce Pediatric Medication Errors in Prehospital Emergency Care

Children in prehospital emergency care are particularly vulnerable to medication errors, often with serious consequences. A prior study analyzing prehospital pediatric medication dosing errors, conducted after the implementation of a statewide pediatric drug-dosing reference for emergency medical services (EMS), identified an alarmingly high error rate. This significant finding led to the current study, which aims to develop technological interventions to reduce the frequency of medication errors for children during treatment by EMS. The current study focuses on the design and development of a safety strategy to automate medication administration using mixed-reality technology. Simulations were conducted to inform the design process, focusing on three scenarios: cardiac arrest, seizure, and burns. The design team included medical and engineering researchers, paramedics, and emergency medical technicians from multiple emergency medical service agencies. Root cause analysis (RCA) and failure mode and effects analysis (FMEA) were conducted after the simulations were completed. The RCA and FMEA were used to identify and prioritize failure points, which were then addressed in a mixed-reality solution using Microsoft HoloLens 2 to automate and enhance pediatric medication administration in prehospital emergency care. The resulting application will provide real-time assistance to guide paramedics through the complicated medication dosing and administration process using a detailed step-by-step guide, aiming to decrease medication errors and improve medication dosing accuracy.

Prehospital point-of-care medication burden as a predictor of poor related outcomes in unselected acute diseases.

How prehospital medication predicts patient outcomes is unclear. The aim of this work was to unveil the association between medication burden administration in prehospital care and short, mid, and long-term mortality (2, 30, and 365day) in unselected acute diseases and to assess the potential of the number of medications administered for short, mid, and long-term mortality prediction. A prospective, multicenter, ambulance-based, cohort study was carried out in adults with unselected acute diseases managed by emergency medical services (EMS). The study was carried out in Spain with 44 ambulances and four hospitals. The principal outcome was cumulative mortality at 2, 30, and 365days. Epidemiological variables, vital signs, and prehospital medications were collected. Patients were classified into four categories: no medication dispensed in prehospital care, one to two medications, three to four medications, and five or more medications. A total of 6401 patients were selected. The 2-day mortality associated with each group was 0.5%, 1.8%, 6.5%, and 18.8%. The 30-day mortality associated with each group was 3.8%, 6.2%, 13.5%, and 31.9%. The 365-day mortality associated with each group was 11%, 15.3%, 25.2%, and 45.7%. The predictive validity of the number of drugs administered, measured by the area under the curve, was 0.808, 0.720, and 0.660 for 2-, 30-, and 365-day mortality, respectively. Our results showed that prehospital drugs could provide relevant information regarding the mortality prediction of patients. The incorporation of this score could improve the management of high-risk patients by the EMS.

Rationale and design of the FRENch CoHort of myocardial Infarction Evaluation (FRENCHIE) study

BackgroundDespite major advances in prevention and treatment, cardiovascular diseases – particularly acute myocardial infarction – remain a leading cause of death worldwide and in France. Collecting contemporary data about the characteristics, management and outcomes of patients with acute myocardial infarction in France is important. AimsThe main objectives are to describe baseline characteristics, contemporary management, in-hospital and long-term outcomes of patients with acute myocardial infarction hospitalized in tertiary care centres in France; secondary objectives are to investigate determinants of prognosis (including periodontal disease and sleep-disordered breathing), to identify gaps between evidence-based recommendations and management and to assess medical care costs for the index hospitalization and during the follow-up period. MethodsFRENCHIE (FRENch CoHort of myocardial Infarction Evaluation) is an ongoing prospective multicentre observational study (ClinicalTrials.gov Identifier: NCT04050956) enrolling more than 19,000 patients hospitalized for acute myocardial infarction with onset of symptoms within 48hours in 35 participating centres in France since March 2019. Main exclusion criteria are age<18 years, lack of health coverage and procedure-related myocardial infarction (types 4a and 5). Detailed information was collected prospectively, starting at admission, including demographic data, risk factors, medical history and treatments, initial management, with prehospital care pathways and medication doses, and outcomes until hospital discharge. The follow-up period (up to 20 years for each patient) is ensured by linking with the French national health database (Système national des données de santé), and includes information on death, hospital admissions, major clinical events, healthcare consumption (including drug reimbursement) and total healthcare costs. FRENCHIE is also used as a platform for cohort-nested studies – currently three randomized trials and two observational studies. ConclusionsThis nationwide large contemporary cohort with very long-term follow-up will improve knowledge about acute myocardial infarction management and outcomes in France, and provide a useful platform for nested studies and trials.

The effect of Chronic treatments of Type 2-diabetes mellitus on COVID-19 Morbidity and Symptoms Severity

Coronavirus disease 2019 (COVID-19) is a highly contagious viral disease that causes the severe acute respiratory syndrome (SARS), and has had a disastrous impact on demographics around the world. Studies have classified type 2-diabetes mellitus (T2DM) as a risk factor for increasing mortality and se-verity of disease symptoms. However, the effect of different T2DM-chronic medications on disease progression is still unclear. The aim of this study was to determine the effect of glycemic control on COVID-19-related mortality and symptom severity, as well as the impact of commonly used T2DM therapeutic approaches on disease outcomes. This study included 109 COVID-19 patients with (68 patients) or without (41 patients) type 2-diabetes mellitus. Diabetic patients were further classified according to: 1) their glycemic control [HbA1c levels ˂6.5% (Well-controlled) and ≥ 6.5% (Less-controlled)], or 2) their pre-hospital anti-hyperglycemic med-ication [metformin (50%) or sulfonylureas (50%)]. Our results showed that diabetes is associated with a significantly higher risk of death in COVID-19 pa-tients. We also found that metformin treatment reduces plasma C-reactive protein levels and mortality Compared with sulfonylureas, and continuing with metformin during the hospital stay had a better prog-nostic for survival. We also, demonstrated that taking sulfonylurea is associated with an increase in COVID-19 mortality as compared to metformin by increasing cardiovascular events.

Hypertension during transfer is associated with poor outcomes in unstable patients with ruptured abdominal aortic aneurysm

ObjectiveLimited data exist for optimal blood pressure (BP) management during transfer of patients with ruptured abdominal aortic aneurysm (rAAA). This study evaluates the effects of hypertension and severe hypotension during interhospital transfers in a cohort of patients with rAAA in hemorrhagic shock. MethodsWe performed a retrospective, single-institution review of patients with rAAA transferred via air ambulance to a quaternary referral center for repair (2003-2019). Vitals were recorded every 5 minutes in transit. Hypertension was defined as a systolic BP of ≥140 mm Hg. The primary cohort included patients with rAAA with hemorrhagic shock (≥1 episode of a systolic BP of <90 mm Hg) during transfer. The primary analysis compared those who experienced any hypertensive episode to those who did not. A secondary analysis evaluated those with either hypertension or severe hypotension <70 mm Hg. The primary outcome was 30-day mortality. ResultsDetailed BP data were available for 271 patients, of which 125 (46.1%) had evidence of hemorrhagic shock. The mean age was 74.2 ± 9.1 years, 93 (74.4%) were male, and the median total transport time from helicopter dispatch to arrival at the treatment facility was 65 minutes (interquartile range, 46-79 minutes). Among the cohort with shock, 26.4% (n = 33) had at least one episode of hypertension. There were no significant differences in age, sex, comorbidities, AAA repair type, AAA anatomic location, fluid resuscitation volume, blood transfusion volume, or vasopressor administration between the hypertensive and nonhypertensive groups. Patients with hypertension more frequently received prehospital antihypertensives (15% vs 2%; P = .01) and pain medication (64% vs 24%; P < .001), and had longer transit times (36.3 minutes vs 26.0 minutes; P = .006). Episodes of hypertension were associated with significantly increased 30-day mortality on multivariable logistic regression (adjusted odds ratio [aOR], 4.71; 95% confidence interval [CI], 1.54-14.39; P = .007; 59.4% [n = 19] vs 40.2% [n = 37]; P = .01). Severe hypotension (46%; n = 57) was also associated with higher 30-day mortality (aOR, 2.82; 95% CI, 1.27-6.28; P = .01; 60% [n = 34] vs 32% [n = 22]; P = .01). Those with either hypertension or severe hypotension (54%; n = 66) also had an increased odds of mortality (aOR, 2.95; 95% CI, 1.08-8.11; P = .04; 58% [n = 38] vs 31% [n = 18]; P < .01). Level of hypertension, BP fluctuation, and timing of hypertension were not significantly associated with mortality. ConclusionsHypertensive and severely hypotensive episodes during interhospital transfer were independently associated with increased 30-day mortality in patients with rAAA with shock. Hypertension should be avoided in these patients, but permissive hypotension approaches should also maintain systolic BPs above 70 mm Hg whenever possible.

Improving Emergency Medicine Clinician Awareness of Prehospital-Administered Medications

Background/problem: Information transfer between emergency medical services (EMS) and emergency medicine (EM) is at high risk for omissions and errors. EM awareness of prehospital medication administration affects patient management and medication error. In April 2020, we surveyed emergency physicians and emergency department nurse practitioners (NPs) and physician assistants (PAs) regarding the EMS handoff process. Emergency physicians and NPs/PAs endorsed knowing what medications were given, or having received direct verbal handoff from EMS “Often” or “Always” only 20% of the time (n = 71), identifying a need to improve the written handoff process. To assess rates of medication error due to lack of awareness of prehospital administered medications, we measured glucocorticoid redosing in the emergency department (ED) following prehospital dexamethasone administration. In 2020, glucocorticoids were redosed 30% of the time, and our aim was to reduce glucocorticoid redosing to 10% by June 2022. Intervention: We developed and implemented a system innovation where prehospital-administered medications documented in a nursing flowsheet during verbal handoff are pulled directly into the triage note where they are more likely to be reviewed by receiving EM clinicians. Results: Shewhart p-charts were used to evaluate for statistical process change in the process measure of triage note documentation of prehospital medication administration and the outcome measure of glucocorticoid redosing. While the frequency of prehospital dexamethasone administration in the triage note increased, no statistical process change outcome measure of glucocorticoid redosing was observed. However, on repeat survey of EM clinicians in July 2022, 50% now indicated they were aware of prehospital medication administration “Often” or “Always” (n = 61, p = 0.003), 87% maintained they use the triage note as the main source of information regarding prehospital medication administration, and 81% “Always” review the triage note. Conclusions: Innovations that improve accessibility of written documentation of prehospital medication administration were associated with improved subjective assessment of EM clinician awareness of prehospital medications, but not the outcome measure of medication error. Effective error reduction likely requires better system integration between prehospital and EM records.

Pediatric status epilepticus management by Emergency Medical Services (the pSERG cohort)

PurposeDelayed treatment in status epilepticus (SE) is independently associated with increased treatment resistance, morbidity, and mortality. We describe the prehospital management pathway and Emergency Medical Services (EMS) timeliness in children who developed refractory convulsive status epilepticus (RCSE). MethodsRetrospective multicenter study in the United States using prospectively collected observational data from June 2011 to March 2020. We selected pediatric patients (one month–21 years) with RCSE initiated outside the hospital and transported to the hospital by EMS. ResultsWe included 91 patients with a median (percentile25-percentile75) age of 3.0 (1.5–7.3) years. The median time from seizure onset to hospital arrival was 45 (30–67) minutes, with a median time cared for by EMS of 24 (15–36) minutes. Considering treatment by caregivers and EMS before hospital arrival, 20 (22%) patients did not receive any anti-seizure medications (ASM) and 71 (78%) received one to five doses of benzodiazepines (BZD), without non-BZD ASM. We provided the prehospital treatment flow path of these patients through caregivers and EMS including relevant time points. Patients with a history of SE were more likely to receive the first BZD in the prehospital setting compared to patients without a history of SE (adjusted HR 3.25, 95% CI 1.72–6.12, p<0.001). ConclusionIn this multicenter study of pediatric RCSE, prehospital treatment may be streamlined further. Patients with a history of SE were more likely to receive prehospital rescue medication.

Risk Factors for Maxillofacial Space Infection Complications: A Retrospective Analysis of 457 Patients.

This study was performed to determine the risk factors associated with systemic complications of maxillofacial space infection (MSI), and to propose an objective evaluation index - severity score of MSI. 457 MSI patients from Jan 2010 to Dec 2020 were reviewed retrospectively. The predictor variables included demographic, origin of infection, underlying systemic disease, pre-hospital medication history, laboratory examinations and severity scores of space infection. The severity score of space infection was proposed to evaluate the airway compromise of anatomic spaces. The primary outcome variable was the complication. The impact factors of complications were analyzed using univariate analysis and multivariate logistic regression. 457 patients were included (average age 46.3y, male to female ratio 1.43:1). Among them, 39 patients developed postoperative complications. In the complication group, there were 18 patients (46.2%) with pulmonary infection, and two patients died. We found that the history of diabetes mellitus (OR=4.74, 95% confidence interval (CI)=2.22, 10.12), high temperature (≥39°C) (OR=4.16, 95% CI=1.43, 12.06), advanced age (≥65y) (OR=2.88, 95% CI=1.37, 6.01), and severity score of space infection (OR=1.14, 95% CI=1.04, 1.25) were independent risk factors for complications of MSI. All the risk factors needed to be closely monitored. Severity score of MSI was an objective evaluation index to predict complications.

ANALGESIA BIAS IN TIBIAL SHAFT FRACTURES: A COMPARISON BETWEEN MAORI AND NON-MAORI

Māori consistently have poorer health outcomes compared to non-Māori within Aotearoa. Numerous worldwide studies demonstrate that ethnic minorities receive less analgesia for acute pain management. We aimed to compare analgesic management of a common orthopaedic injury, tibial shaft fracture, between Māori and non-Māori.A retrospective cohort study from January 1st, 2015, to December 31st 2020 inclusive. Eligible patients were 16-65 years old and had isolated closed tibial shaft fractures. 104 patients were included in the study, 48 Māori and 56 Non-Māori. Baseline demographics were similar between the 2 cohorts. The primary outcome measure was type of analgesia charted on the ward. Secondary outcome measures were pre-hospital medications given, pain scores on arrival to the emergency department (ED) and the ward, time to analgesia in ED and type of analgesia given in ED. Statistics were calculated using Fisher's exact test, Pearson's chi-squared test or Wilcoxson's rank sum test as appropriateNo statistically significant differences were found in opiates or synthetics charted to Māori vs Non-Māori (83% vs 89% and 77% vs 88% respectively), opiates given in ED, time to analgesia in ED or ED and ward arrival pain scores. Of statistical significance is that Māori were less likely to receive pre-hospital medication compared to Non-Māori (54% vs 80% respectively, p=0.004)Māori were significantly less likely to receive pre-hospital pain medication compared to Non-Māori. However no other statistically significant findings were found when comparing pain scores, time to analgesia or type of pain relief charted for Māori vs non-Māori.The reasons for Māori receiving significantly less prehospital medication were not explored in this study and further investigation is required to reduce the bias that exists in this area.

An Analysis of Prehospital Pediatric Medication Dosing Errors after Implementation of a State-Wide EMS Pediatric Drug Dosing Reference

Background Medication dosing errors are common in prehospital pediatric patients. Prior work has shown the overall medication error rate by emergency medical services (EMS) in Michigan was 34.7%. To reduce these errors, the state of Michigan implemented a pediatric dosing reference in 2014 listing medication doses and volume to be administered. Objective To examine changes in pediatric dosing errors by EMS in Michigan after implementation of the pediatric dosing reference. Methods We conducted a retrospective review of the Michigan Emergency Medical Services Information System of children ≤ 12 years of age from June 2016–May 2017 treated by 16 EMS agencies. Agencies were a mix of public, private, third-service, and fire-based. A dosing error was defined as >20% deviation from the weight-appropriate dose listed on the pediatric dosing reference. Descriptive statistics with confidence intervals and standard deviations are reported. Results During the study period, there were 9,247 pediatric encounters, of whom 727 (7.9%) received medications and are included in the study. There were 1078 medication administrations, with 380 dosing errors (35.2% [95% CI 25.3–48.4]). The highest error rates were for dextrose 50% (3/4 or 75% [95% CI 32.57–100.0]) and glucagon (3/4 or 75% [95% CI 32.57–100.0]). The next highest proportions of incorrect doses were opioids: intranasal fentanyl (11/16 or 68.8% [95% CI 46.04–91.46]) and intravenous fentanyl (89/130 or 68.5% [95% CI 60.47–76.45]). Morphine had a much lower error rate (24/51 or 47.1% [95% CI 33.36–60.76]). Midazolam had the third highest error rate, for intravenous (27/50 or 54.0% [95% CI (40.19–67.81]) and intramuscular (25/68 or 36.8% [95% CI 40.19–67.81]) routes. Epinephrine 1 mg/10 ml had an incorrect dosage rate of 35/119 (29.4% [95% CI 20.64–36.99]). Asthma medications had the lowest rate of incorrect dosing (albuterol sulfate 9/247 or 3.6% [95% CI 1.31–5.98]). Conclusions Medications administered to prehospital pediatric patients continue to demonstrate dosing errors despite pediatric dosing reference implementation. Although there have been improvements in error rates in asthma medications, the overall error rate has increased. Continued work to build patient safety strategies to reduce pediatric medication dosing errors by EMS is needed.

Racial and Ethnic Disparity in Prehospital Pain Management for Trauma Patients.

Although evidence suggests that racial and ethnic minority (REM) patients receive inadequate pain management in the acute care setting, it remains unclear whether these disparities also occur during the prehospital period. The aim of this study is to assess the impact of race and ethnicity on prehospital analgesic use by emergency medical services (EMS) in trauma patients. Retrospective chart review of adult trauma patients aged 18 to 89 years old transported by EMS to our American College of Surgeons-verified level 1 trauma center from 2014 to 2020. Patients who identified as Black, Asian, Native American, or Other for race and/or Hispanic or Latino or Unknown for ethnicity were considered REM. Patients who identified as White, non-Hispanic were considered White. Groups were compared in univariate and multivariate analysis. The primary outcome was prehospital analgesic administration. A total of 2,476 patients were transported by EMS (47% White and 53% REM). White patients were older on average (46 years vs 38 years; p < 0.001) and had higher rates of blunt trauma (76% vs 60%; p < 0.001). There were no differences in Injury Severity Score (21 vs 20; p = 0.22). Although REM patients reported higher subjective pain rating (7.2 vs 6.6; p = 0.002), they were less likely to get prehospital pain medication (24% vs 35%; p < 0.001), and that difference remained significant after controlling for baseline characteristics, transport method, pain rating, prehospital hypotension, and payor status (adjusted odds ratio [95% CI], 0.67 [0.47 to 0.96]; p = 0.03). Patients from racial and ethnic minority groups were less likely to receive prehospital pain medication after traumatic injury than White patients. Forms of conscious and unconscious bias contributing to this inequity need to be identified and addressed.

Association between prehospital medication and fatal outcomes in a cohort of hospitalized patients due to coronavirus disease-2019 in a referral hospital in Peru

BackgroundTo explore the association between the use of prehospital medications and the development of fatal outcomes in patients who required hospitalization due to coronavirus disease-2019 (COVID-19). MethodsThis retrospective cohort study included adult patients who were hospitalized due to COVID-19. Demographic, clinical, and laboratory data, prehospital medication history, and fatal outcome development (use of high-flow oxygen therapy, intensive care unit [ICU] admission, or mortality) were extracted from the medical records of patients who were admitted due to COVID-19 to the Carlos Seguín Escobedo National Hospital of Arequipa, Peru during July to September 2021, the period after the second wave of COVID-19 cases in Peru. Survival was analyzed using the Cox proportional hazards model, and crude hazard ratios and adjusted hazard ratios (aHR) with their respective 95% confidence intervals (95% CI) were calculated. ResultsA total of 192 patients were evaluated, of whom 62% were males and 46.9% did not require oxygen support at admission. Additionally, 64.6% used nonsteroidal anti-inflammatory drugs, 35.4% used corticosteroids, 28.1% used macrolides or ceftriaxone, 24.5% used ivermectin, and 21.9% used warfarin before hospitalization. Of the patients, 30.2% developed a fatal outcome during follow-up. The multivariate analysis revealed that prehospital corticosteroid use was independently associated with the fatal outcome due to COVID-19 with an aHR = 5.29 (95%CI: 1.63–17.2). ConclusionPrehospital corticosteroid use was associated with a 5-fold increased risk of fatal outcome development.

A new medication-based prediction score for postoperative delirium in surgical patients: Development and proof of feasibility in a retrospective patient cohort.

Structured risk screening for postoperative delirium (POD) considering prehospital medication is not established. We aimed to develop a POD-risk prediction score based on known risk factors and delirium-risk increasing drugs to be used by pharmacists during medication reconciliation at hospital admission, and to test for feasibility in a retrospective cohort of surgical patients. Therefore, established POD-risk factors and drugs were extracted from the literature and a score was generated. Following this, the score was tested for feasibility in a retrospective 3-month-cohort of surgical patients. For patients with higher scores suggesting higher probability of POD, patient charts were screened for documentation of POD. For development of the score, the following POD-risk factors were defined and points assigned for score calculation: age (≥65 years=1 point/≥75 years=2), male sex (1), renal insufficiency (RI; 1), hepatic impairment (HI; Model-of-endstage-liver-disease (MELD) 10-14=1/≥15=2), delirium-risk increasing drugs (1 point per drug class), anticholinergic drug burden (ACB; ≥3=1). In the retrospective test cohort of 1174 surgical patients these factors concerned: age ≥65 years 567 patients (48%)/≥75 years 303 (26%), male 652 (55%), RI 238 (20%), MELD 10-14 106 (9%)/≥15 65 (5%), ≥ 1 delirium-risk increasing drug 418 (36%), ACB ≥3 106 (9%). The median POD-risk prediction score was 2 (range 0-9). Of 146 patients (12%) with a score ≥ 5, POD was documented for 43 (30%), no evidence for POD for 91 (62%) and data inconclusive for 12 (8%). For scores of ≥ 7, POD was documented for 50% of the patients with sufficient POD documentation. Overall, POD documentation was poor. To summarize, we developed and successfully tested the feasibility of a POD-prediction-score assessable by pharmacists at medication reconciliation at hospital admission.

Association Between Perioperative Medication Use and Postoperative Delirium and Cognition in Older Adults Undergoing Elective Noncardiac Surgery.

Postoperative delirium is frequent in older adults and is associated with postoperative neurocognitive disorder (PND). Studies evaluating perioperative medication use and delirium have generally evaluated medications in aggregate and been poorly controlled; the association between perioperative medication use and PND remains unclear. We sought to evaluate the association between medication use and postoperative delirium and PND in older adults undergoing major elective surgery. This is a secondary analysis of a prospective cohort study of adults ≥70 years without dementia undergoing major elective surgery. Patients were interviewed preoperatively to determine home medication use. Postoperatively, daily hospital use of 7 different medication classes listed in guidelines as risk factors for delirium was collected; administration before delirium was verified. While hospitalized, patients were assessed daily for delirium using the Confusion Assessment Method and a validated chart review method. Cognition was evaluated preoperatively and 1 month after surgery using a neurocognitive battery. The association between prehospital medication use and postoperative delirium was assessed using a generalized linear model with a log link function, controlling for age, sex, type of surgery, Charlson comorbidity index, and baseline cognition. The association between daily postoperative medication use (when class exposure ≥5%) and time to delirium was assessed using time-varying Cox models adjusted for age, sex, surgery type, Charlson comorbidity index, Acute Physiology and Chronic Health Evaluation (APACHE)-II score, and baseline cognition. Mediation analysis was utilized to evaluate the association between medication use, delirium, and cognitive change from baseline to 1 month. Among 560 patients enrolled, 134 (24%) developed delirium during hospitalization. The multivariable analyses revealed no significant association between prehospital benzodiazepine (relative risk [RR], 1.44; 95% confidence interval [CI], 0.85-2.44), beta-blocker (RR, 1.38; 95% CI, 0.94-2.05), NSAID (RR, 1.12; 95% CI, 0.77-1.62), opioid (RR, 1.22; 95% CI, 0.82-1.82), or statin (RR, 1.34; 95% CI, 0.92-1.95) exposure and delirium. Postoperative hospital benzodiazepine use (adjusted hazard ratio [aHR], 3.23; 95% CI, 2.10-4.99) was associated with greater delirium. Neither postoperative hospital antipsychotic (aHR, 1.48; 95% CI, 0.74-2.94) nor opioid (aHR, 0.82; 95% CI, 0.62-1.11) use before delirium was associated with delirium. Antipsychotic use (either presurgery or postsurgery) was associated with a 0.34 point (standard error, 0.16) decrease in general cognitive performance at 1 month through its effect on delirium (P = .03), despite no total effect being observed. Administration of benzodiazepines to older adults hospitalized after major surgery is associated with increased postoperative delirium. Association between inhospital, postoperative medication use and cognition at 1 month, independent of delirium, was not detected.

Retrospective identification of medication related adverse events in the emergency medical services through the analysis of a patient safety register

Adverse drug events encompass a wide range of potential unintended and harmful events, from adverse drug reactions to medication errors, many of which in retrospect, are considered preventable. However, the primary challenge towards reducing their burden lies in consistently identifying and monitoring these occurrences, a challenge faced across the spectrum of healthcare, including the emergency medical services. The aim of this study was to identify and describe medication related adverse events (AEs) in the out-of-hospital setting. The medication components of a dedicated patient safety register were analysed and described for the period Jan 2017–Sept 2020. Univariate descriptive analysis was used to summarize and report on basic case and patient demographics, intervention related AEs, medication related AEs, and AE severity. Multivariable logistic regression was used to assess the odds of AE severity, by AE type. A total of 3475 patient records were assessed where 161 individual medication AEs were found in 150 (4.32%), 12 of which were categorised as harmful. Failure to provide a required medication was found to be the most common error (1.67%), followed by the administration of medications outside of prescribed practice guidelines (1.18%). There was evidence to suggest a 63% increase in crude odds of any AE severity [OR 1.63 (95% CI 1.03–2.6), p = 0.035] with the medication only AEs when compared to the intervention only AEs. Prehospital medication related adverse events remain a significant threat to patient safety in this setting and warrant greater widespread attention and future identification of strategies aimed at their reduction.

'Double Whamm' and 'Triple Whamm' combinations in hospitalized surgical patients - real life data from a tertiary teaching hospital.

The 'Triple-Whamm'-combination (TW) of renin-angiotensin-aldosteron-system-inhibitors (RAASI), diuretics and non-steroidal anti-inflammatory drugs (NSAID) can cause acute kidney injury (AKI), especially with additional risk factors like chronic kidney disease (CKD) or surgery. Thus, patients on 'Double-Whammy'-combination (DW) of RAASI and diuretics should receive postoperative NSAID only following risk-benefit-evaluation. Currently, there are no data how often surgical patients take DW/TW at admission and postoperatively. The objective of this study was to firstly assess the prevalence of DW/TW-patients, secondly, to evaluate postoperative NSAID use in DW-patients and possible effects on renal function (RF). In a seven-month retrospective study, the pre-hospital medication of patients admitted to surgical wards of a tertiary teaching hospital was screened for intake of TW-drugs and renal impairment (RI; eGFR <60 ml/min/1.73 m 2 ), respectively. For patients admitted with a DW-combination of RAASI and diuretic and undergoing surgery, postoperative NSAID use was recorded and checked against internal guidelines for postoperative pain management recommending as first line NSAID therapy ibuprofen in bone surgery and novaminsulfone in visceral surgery. If NSAID were taken, RF was followed for five days. Of 2007 patients, 343 (17.1%) presented with DW in pre-hospital medication and 28 (1.4%) with TW, which 19/28 (67.9%) took only on demand. Upon admission, RI was present in 113 (32.9%) DW-patients and 9 (33.3%) TW-patients. 227/343 (66.2%) DW-patients underwent surgery and 34/227 (15.0%) were prescribed postoperative NSAID. 24/227 (10.6%) actually received NSAID and 4/24 (16.7%) had a decrease of RF with one showing AKI. In our hospitalized surgical patients, TW-combination in pre-hospital medication was rare. The intake of DW-combination was common but only a small number actually received NSAID after surgery. When a TW-combination was given postoperatively, renal function decreased in every sixth patient. Thus, the absolute number of AKI following a TW-combination was small, however, the individual risk for TW-caused AKI should be considered when choosing postoperative pain management. Guidelines for postoperative NSAID use should consider the patient individual risk factors for AKI, thereby increasing drug safety.

Effect of a Mobile App on Prehospital Medication Errors During Simulated Pediatric Resuscitation: A Randomized Clinical Trial

Effect of a Mobile App on Prehospital Medication Errors During Simulated Pediatric Resuscitation: A Randomized Clinical Trial

Sources of medication omissions among hospitalized older adults with polypharmacy.

Hospitalized older adults have a high prevalence of polypharmacy and medication inaccuracies. Gathering the best possible medication history (BPMH) is necessary to accurately identify each medication for multimorbid older adults. The objective was to describe a multipronged approach to obtaining the BPMH for hospitalized older adults, quantify the medication discrepancies identified through these sources, and explore factors associated with these discrepancies. Cross-sectional analysis of 372 hospitalized older adults (age ≥ 50) transitioning to post-acute care as part of a randomized controlled trial to reduce medication burden. We used four information sources to yield a BPMH. Medication discrepancies at hospital admission were categorized as omissions, additions, and dose discrepancies after comparing alternate sources with the electronic medical record (EMR). Multivariate regression analysis, including patient factors (e.g., age, prehospital medication count, number of pharmacies), was performed to identify factors associated with the total count of medication discrepancies. Ninety percent of participants had at least one medication discrepancy and 46% used more than one pharmacy. The majority of discrepancies were omissions. Among the entire cohort, there was a median of two omitted medications per patient across two alternate sources-pharmacy refill history and bedside interview. Lower age, greater total number of prehospital medications, and admission from assisted living or skilled nursing facility were significantly associated with greater medication discrepancies. A multipronged and consistent approach to obtain a BPMH during hospitalization for multimorbid older adults revealed medication discrepancies that should be addressed prior to hospital discharge to support safe prescribing practices.

QTc-time-prolongating drugs and additional risk factors for long-QT-syndrome at hospital admission of surgical patients - risk assessment by pharmacists.

Drugs can cause long-QTc-syndrome (LQTS), thereby elevating the risk for palpitations, syncopes, and sudden cardiac death. Additional risk factors such as the intake of more than one QTc-prolongating drug (QTPD) and surgery (cardiac and non-cardiac) increase the risk considerably. Therefore, a good knowledge of patientś perioperative risk is important. Data concerning this issue in surgical patients is, however, scarce. We aimed to determine the number of surgical patients taking QTPD at hospital admission and to assess the presence of additional risk factors for LQTS. In addition, we determined the LQTS-risk at hospital admission by calculating the Tisdale Risk Score, enabling early detection of patients at risk. In a retrospective study, the pre-hospital medication of a 4-month cohort of surgical patients admitted to a tertiary teaching hospital was evaluated for QTPD-intake. For these patients, additional risk factors for LQTS were assessed and the Tisdale Risk Score was calculated. Of 837 surgical patients, 419 (50%) took at least one QTPD. In total, 3,376 drugs were taken and 723 (21%) classified as QTPD with a median number of 2 (range 1-8) per patient. The median number of LQTS-risk factors for these patients at hospital admission was 2 (range 0-5). The Tisdale Risk Score classified 23 patients (5%) as high, 187 (45%) as moderate, and 209 (50%) as low risk. These findings indicate a high number of surgical patients with QTPD and additional risk factors. The Tisdale Risk Score can be used as a screening instrument for patients at risk for QTc-prolongation during medication reconciliation by pharmacists at hospital admission. Patients identified as high and moderate risk should be evaluated for adjustable risk factors and monitored adequately. Medical treatment needs to be chosen carefully in view of in-hospital patient safety.