[Patients admitted to the intensive care unit for iatrogenic disease. Risk factors and consequences]

Characterization of adverse drug reactions causing admission to an intensive care unit

AIMS

This study aimed to determine the occurrence of adverse drug reactions (ADRs) that caused admission to the intensive care unit (ICU) of a university hospital.

METHODS

Clinical records were reviewed for patients meeting the inclusion criteria who were admitted to the ICU between September and December 2012. Suspected cases of ADRs were documented. Nine researchers later evaluated causality using the Naranjo Algorithm, preventability using the Schumock and Thornton criteria, and clinical classification based on the dose-time-susceptibility system.

RESULTS

In total, 96 patients presented 108 cases of ADR (13.8%, 95% confidence interval 11.2-16.4%) as the cause of admission. The most frequent ADRs were bradyarrhythmias and upper gastrointestinal bleeding (12%). Therapeutic failure accounted for 20%. The most commonly associated medications were acetylsalicylic acid (16%) and losartan (10%). Forty-six cases were categorized as possible, and only one as definite. According to the dose-time-susceptibility classification, in 82% of the cases, the dosage was collateral (within the therapeutic range), and 90% were independent of time; the factors most associated with susceptibility to ADRs were comorbidities (42%) and age (49%). Forty-four percent of the ADRs were considered possibly preventable.

CONCLUSIONS

ADRs contribute significantly to ICU admissions, and a significant number of ADRs are preventable. National studies are needed to assess their incidence and to establish classification standards to reduce their clinical impact.

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

RATIONALE, AIMS AND OBJECTIVES

Adverse events are unintended patient injuries or complications that arise from health care management resulting in death, disability or prolonged hospital stay. Adverse events that require critical care are a considerable financial burden to the health care system, but also their global impact on patients and society is probably underestimated. The objectives of this systematic review were to synthesize the best available evidence regarding the estimates of the incidence and preventability of adverse events that necessitate intensive care admission, to determine the type and consequences [mortality, length of intensive care unit (ICU) stay and costs] of these adverse events.

METHODS

MEDLINE (from 1966 to present), EMBASE (from 1974 to present) and CENTRAL (version 1-2010) were searched for studies reporting on unplanned admissions on ICUs. Several other sources were searched for additional studies. Only quantitative studies that used chart review for the detection of adverse events requiring intensive care admission were considered for eligibility. For the purposes of this systematic review, ICUs were defined as specialized hospital facilities which provide continuous monitoring and intensive care for acutely ill patients. Studies that were published in the English, Dutch, German, French or Spanish language were eligible for inclusion. Two reviewers independently extracted data and assessed the methodological quality of the included studies.

RESULTS

A total of 27 studies were reviewed. Meta-analysis of the data was not appropriate because of methodological and statistical heterogeneity between studies; therefore, results are presented in a descriptive way. The percentage of surgical and medical adverse events that required ICU admission ranged from 1.1% to 37.2%. ICU readmissions varied from 0% to 18.3%. Preventability of the adverse events varied from 17% to 76.5%. Preventable adverse events are further synthesized by type of event. Consequences of the adverse events included a mean length of ICU stay that ranged from 1.5 days to 10.4 days for the patient's first stay in ICU and mortality percentages between 0% and 58%.

CONCLUSIONS

Adverse events are an important reason for (re)admission to the ICU and a considerable proportion of these are preventable. It was not possible to estimate an overall incidence and preventability rate of these events as we found considerable heterogeneity. To decrease adverse events that necessitate ICU admission, several systems are recommended such as early detection of patients with clinical instability on general wards and the implementation of rapid response teams. Step-down or intermediate care units could be a useful strategy for patients who require monitoring to avoid ICU readmissions. However, the effectiveness of such systems needs to be investigated.

Iatrogenic disease in the elderly: risk factors, consequences, and prevention

The epidemiology of iatrogenic disease in the elderly has not been extensively reported. Risk factors of iatrogenic disease in the elderly are drug-induced iatrogenic disease, multiple chronic diseases, multiple physicians, hospitalization, and medical or surgical procedures. Iatrogenic disease can have a great psychomotor impact and important social consequences. To identify patients at high risk is the first step in prevention as most of the iatrogenic diseases are preventable. Interventions that can prevent iatrogenic complications include specific interventions, the use of a geriatric interdisciplinary team, pharmacist consultation and acute care for the elderly units.

Assessment of an unplanned admission to the intensive care unit as a global safety indicator in surgical patients

An unplanned intensive care unit admission within 24 hours of a procedure with an anaesthetist in attendance (UIA) is a recommended clinical indicator It is designed to identify preventable iatrogenic complications. Often understood as a specific anaesthetic outcome, its value has been repeatedly questioned. Iatrogenic complications however often result from successive mishaps. In the specific context of an UIA these complications can be related both to anaesthesia and surgery. UIA is therefore probably more a global indicator of the safety of surgical care (anaesthetic and surgical) rather than a specific anaesthetic outcome. Its utility as such is however unknown. The purpose of this study was to assess the value of UIA as a global measure of avoidable iatrogenic complications in surgical patients. Using computerised patient records and medical charts, all patients with an UIA over a study period of five years were identified. The proportion, cause and preventability of iatrogenic complications amongst these patients were assessed. A total of 188 UIA patients were identified by peer reviewers. Of these, 87% to 92% had a complication caused by anaesthesia and/or surgery. Anaesthesia was found to be responsible for 24% to 31% of iatrogenic complications. All other cases related to the combination of anaesthesia and surgery or surgery alone. Of these, 74% to 92% of complications were found to be preventable. Despite intrinsic limitations of the retrospective chart review method, UIA can be considered as a valuable tool to detect avoidable iatrogenic complications related to both surgical and anaesthetic care.