Clinical Decision Rules to Improve the Detection of Adverse Drug Events in Emergency Department Patients

Authors

  • Corinne M. Hohl MD,

    1. From the Department of Emergency Medicine (CMH, GSH, JRB), the Department of Statistics (EY), the Department of Pharmaceutical Sciences (CPA), and the School of Population and Public Health (MOW, SBS, JS), University of British Columbia, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (CMH, JRB) and Pharmacy Services (WWYC), Vancouver General Hospital, Vancouver, British Columbia, Canada; the Centre for Clinical Epidemiology & Evaluation (CMH, EY, JRB), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (GSH) and the Centre for Health Evaluation and Outcome Sciences (JS), St. Paul’s Hospital, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (FH), University of Washington Medical Center, Seattle, WA; and the Vernon Jubilee Hospital (CPA), Vernon, British Columbia, Canada.
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  • Eugenia Yu MSc,

    1. From the Department of Emergency Medicine (CMH, GSH, JRB), the Department of Statistics (EY), the Department of Pharmaceutical Sciences (CPA), and the School of Population and Public Health (MOW, SBS, JS), University of British Columbia, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (CMH, JRB) and Pharmacy Services (WWYC), Vancouver General Hospital, Vancouver, British Columbia, Canada; the Centre for Clinical Epidemiology & Evaluation (CMH, EY, JRB), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (GSH) and the Centre for Health Evaluation and Outcome Sciences (JS), St. Paul’s Hospital, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (FH), University of Washington Medical Center, Seattle, WA; and the Vernon Jubilee Hospital (CPA), Vernon, British Columbia, Canada.
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  • Garth S. Hunte MD,

    1. From the Department of Emergency Medicine (CMH, GSH, JRB), the Department of Statistics (EY), the Department of Pharmaceutical Sciences (CPA), and the School of Population and Public Health (MOW, SBS, JS), University of British Columbia, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (CMH, JRB) and Pharmacy Services (WWYC), Vancouver General Hospital, Vancouver, British Columbia, Canada; the Centre for Clinical Epidemiology & Evaluation (CMH, EY, JRB), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (GSH) and the Centre for Health Evaluation and Outcome Sciences (JS), St. Paul’s Hospital, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (FH), University of Washington Medical Center, Seattle, WA; and the Vernon Jubilee Hospital (CPA), Vernon, British Columbia, Canada.
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  • Jeffrey R. Brubacher MD,

    1. From the Department of Emergency Medicine (CMH, GSH, JRB), the Department of Statistics (EY), the Department of Pharmaceutical Sciences (CPA), and the School of Population and Public Health (MOW, SBS, JS), University of British Columbia, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (CMH, JRB) and Pharmacy Services (WWYC), Vancouver General Hospital, Vancouver, British Columbia, Canada; the Centre for Clinical Epidemiology & Evaluation (CMH, EY, JRB), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (GSH) and the Centre for Health Evaluation and Outcome Sciences (JS), St. Paul’s Hospital, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (FH), University of Washington Medical Center, Seattle, WA; and the Vernon Jubilee Hospital (CPA), Vernon, British Columbia, Canada.
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  • Faegheh Hosseini PharmD,

    1. From the Department of Emergency Medicine (CMH, GSH, JRB), the Department of Statistics (EY), the Department of Pharmaceutical Sciences (CPA), and the School of Population and Public Health (MOW, SBS, JS), University of British Columbia, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (CMH, JRB) and Pharmacy Services (WWYC), Vancouver General Hospital, Vancouver, British Columbia, Canada; the Centre for Clinical Epidemiology & Evaluation (CMH, EY, JRB), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (GSH) and the Centre for Health Evaluation and Outcome Sciences (JS), St. Paul’s Hospital, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (FH), University of Washington Medical Center, Seattle, WA; and the Vernon Jubilee Hospital (CPA), Vernon, British Columbia, Canada.
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  • Chelsea P. Argent BPharm,

    1. From the Department of Emergency Medicine (CMH, GSH, JRB), the Department of Statistics (EY), the Department of Pharmaceutical Sciences (CPA), and the School of Population and Public Health (MOW, SBS, JS), University of British Columbia, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (CMH, JRB) and Pharmacy Services (WWYC), Vancouver General Hospital, Vancouver, British Columbia, Canada; the Centre for Clinical Epidemiology & Evaluation (CMH, EY, JRB), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (GSH) and the Centre for Health Evaluation and Outcome Sciences (JS), St. Paul’s Hospital, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (FH), University of Washington Medical Center, Seattle, WA; and the Vernon Jubilee Hospital (CPA), Vernon, British Columbia, Canada.
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  • Winnie W.Y. Chan BPharm,

    1. From the Department of Emergency Medicine (CMH, GSH, JRB), the Department of Statistics (EY), the Department of Pharmaceutical Sciences (CPA), and the School of Population and Public Health (MOW, SBS, JS), University of British Columbia, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (CMH, JRB) and Pharmacy Services (WWYC), Vancouver General Hospital, Vancouver, British Columbia, Canada; the Centre for Clinical Epidemiology & Evaluation (CMH, EY, JRB), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (GSH) and the Centre for Health Evaluation and Outcome Sciences (JS), St. Paul’s Hospital, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (FH), University of Washington Medical Center, Seattle, WA; and the Vernon Jubilee Hospital (CPA), Vernon, British Columbia, Canada.
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  • Matthew O. Wiens PharmD,

    1. From the Department of Emergency Medicine (CMH, GSH, JRB), the Department of Statistics (EY), the Department of Pharmaceutical Sciences (CPA), and the School of Population and Public Health (MOW, SBS, JS), University of British Columbia, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (CMH, JRB) and Pharmacy Services (WWYC), Vancouver General Hospital, Vancouver, British Columbia, Canada; the Centre for Clinical Epidemiology & Evaluation (CMH, EY, JRB), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (GSH) and the Centre for Health Evaluation and Outcome Sciences (JS), St. Paul’s Hospital, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (FH), University of Washington Medical Center, Seattle, WA; and the Vernon Jubilee Hospital (CPA), Vernon, British Columbia, Canada.
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  • Samuel B. Sheps MD,

    1. From the Department of Emergency Medicine (CMH, GSH, JRB), the Department of Statistics (EY), the Department of Pharmaceutical Sciences (CPA), and the School of Population and Public Health (MOW, SBS, JS), University of British Columbia, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (CMH, JRB) and Pharmacy Services (WWYC), Vancouver General Hospital, Vancouver, British Columbia, Canada; the Centre for Clinical Epidemiology & Evaluation (CMH, EY, JRB), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (GSH) and the Centre for Health Evaluation and Outcome Sciences (JS), St. Paul’s Hospital, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (FH), University of Washington Medical Center, Seattle, WA; and the Vernon Jubilee Hospital (CPA), Vernon, British Columbia, Canada.
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  • Joel Singer PhD

    1. From the Department of Emergency Medicine (CMH, GSH, JRB), the Department of Statistics (EY), the Department of Pharmaceutical Sciences (CPA), and the School of Population and Public Health (MOW, SBS, JS), University of British Columbia, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (CMH, JRB) and Pharmacy Services (WWYC), Vancouver General Hospital, Vancouver, British Columbia, Canada; the Centre for Clinical Epidemiology & Evaluation (CMH, EY, JRB), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (GSH) and the Centre for Health Evaluation and Outcome Sciences (JS), St. Paul’s Hospital, Vancouver, British Columbia, Canada; the Department of Emergency Medicine (FH), University of Washington Medical Center, Seattle, WA; and the Vernon Jubilee Hospital (CPA), Vernon, British Columbia, Canada.
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  • Best paper award, American College of Emergency Physicians Research Forum, San Francisco, CA, October 2011.

  • This study was supported by grants from the Canadian Patient Safety Institute, the Michael Smith Foundation for Health Research, and the Vancouver Coastal Health Authority. None of the sponsors had any role in study design, data collection or processing, or analysis or preparation of the manuscript. All authors had access to the study data and agreed to submit the manuscript in its current form. The authors have no potential conflicts of interest to disclose.

  • Supervising Editor: Mark B. Mycyk, MD.

Address for correspondence and reprints: Corinne M. Hohl, MD; e-mail: chohl@interchange.ubc.ca.

Abstract

ACADEMIC EMERGENCY MEDICINE 2012; 19:640–649 © 2012 by the Society for Academic Emergency Medicine

Abstract

Objectives:  Adverse drug events (ADEs) are unintended and harmful consequences of medication use. They are associated with high health resource use and cost. Yet, high levels of inaccuracy exist in their identification in clinical practice, with over one-third remaining unidentified in the emergency department (ED). The study objective was to derive clinical decision rules (CDRs) that are sensitive for the detection of ADEs, allowing their systematic identification early in a patient’s hospital course.

Methods:  This was a prospective observational cohort study carried out in two Canadian tertiary care hospitals. Participants were adults presenting to the ED having ingested at least one prescription or over-the-counter medication within 2 weeks. Nurses and physicians evaluated patients for standardized clinical findings. A second evaluator performed interobserver assessments of predictor variables in a subset of patients. Pharmacists, who were blinded to the predictor variables, evaluated all patients for ADEs. An independent committee reviewed and adjudicated cases where the ADE assessment was uncertain or the pharmacist’s diagnosis differed from the physician’s working diagnosis. The primary outcome was an ADE that required a change in medical therapy, diagnostic testing, consultation, or hospital admission. CDRs were derived using kappa coefficients, chi-square statistics, and recursive partitioning.

Results:  Among 1,591 patients, 131 (8.2%, 95% confidence interval [CI] = 7.0% to 9.7%) were diagnosed with the primary outcome. The following variables were associated with ADEs and were used to derive two CDRs: 1) presence of comorbid conditions, 2) antibiotic use within 7 days, 3) medication changes within 28 days, 4) age ≥80 years, 5) arrival by ambulance, 6) triage acuity, 7) recent hospital admission, 8) renal failure, and 9) use of three or more prescription medications. The more sensitive rule had a sensitivity of 96.7% (95% CI = 91.8% to 98.6%) and required 40.8% (95% CI = 37.7% to 42.9%) of patients to have medication review. The more specific rule had a sensitivity 90.8% (95% CI = 81.4% to 95.7%) and required 28.3% of patients to proceed to medication review.

Conclusions:  The authors derived CDRs that identified patients with ADEs with high sensitivity. These rules may improve the identification of ADEs early in a patient’s hospital course while limiting the number of patients requiring a detailed medication review.

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