700,000 drug reaction cases in EDs each year: Nurses are first to ID them
Connect a patient's symptoms with their medications
Shortness of breath. Rashes. Facial swelling. Fatigue. Itching. Hypotension. Dizziness. Confusion. Any one of these symptoms, and dozens of others, could be caused by an adverse drug event (ADE).
New research says 700,000 patients come to EDs each year because of ADEs, and this number is expected to increase because of more older patients, more chronic conditions treated with drugs, and development of new medications, says Daniel S. Budnitz, MD, MPH, the study's author and a researcher in the Centers for Disease Control and Prevention's (CDC's) Division of Healthcare Quality Promotion.1 Researchers analyzed data from the National Electronic Injury Surveillance System to determine the number of ED visits for ADEs from January 2004 through December 2005. Over the two-year period, 21,298 ADE cases were reported.
"Based on data from a nationally representative surveillance system of 63 hospitals, we estimate that more than 700,000 patients were treated for ADEs in all U.S. EDs annually in 2004 and 2005," says Budnitz.
Patients 65 or older were more than twice as likely to be treated in EDs for an ADE and were nearly seven times as likely to be admitted. "Many factors contribute to the disproportionate effect of ADEs on older patients, including the greater number of drugs used by these patients and age-related physiologic changes," says Budnitz.
When evaluating a patient's chief complaint, always consider that the cause may be an ADE, says Jennifer Wilbeck, MSN, APRN, CEN, a nurse practitioner in the ED at Centennial Medical Center in Nashville, TN. "Be prepared to recognize potential adverse effects, allergic reactions, and overdoses, and respond appropriately," she says. Recently, an elderly woman complaining of severe fatigue handed Wilbeck a bag filled with medications. By the time the woman's bag was empty, she had produced four bottles all containing the same medication: atenolol. The patient had seen several providers and was given multiple prescriptions for the same drug.
"She was taking the medication just as prescribed — just in four times the normal dose," says Wilbeck. "I was easily able to diagnose the cause of her fatigue."
ED nurses play a key role in identifying ADEs by documenting a complete medication history in patients, says Budnitz.
In addition to documenting prescription medications, over-the-counter medications, vitamins, and dietary supplements, list any recent medication changes, any confusion reported by the patient about their medication regimen, and medications being taken by the patient that were originally prescribed for someone else, advises Budnitz.
To improve care of patients with ADEs in your ED, do the following:
• Connect the patient's medications to their symptoms.
Patients don't always link their medications to the current problems they are having. That's why you must have a high index of suspicion, says Wilbeck. "The list of patient's home medications must always be running through everyone's head as a possible explanation for their presenting complaint," she says.
• Treat according to the patient's overall health.
Treatments for ADEs depend not only on the medications involved, but also on the patient's symptoms, says Wilbeck. "Also take into consideration the patient's overall health. Can they tolerate the adverse side effects or do they need immediate intervention?" she asks. "It's often not a clear-cut path when deciding how to treat the patient."
For example, a woman came to Centennial's ED four days after joint arthroscopy with bleeding in one of the incisions. After the surgery, she had developed pulmonary emboli and was placed on blood thinners. "The patient needed us to reverse the warfarin so that we could stop the bleeding, but that could have worsened her lung problems," says Wilbeck.
Initially, nurses added bulky pressure dressings in an attempt to stop the patient's leg from bleeding. "Close monitoring of the bleeding by the nurses was essential to determine if the compression dressings were adequate to stop the bleeding or if we would have to actually give the patient some medication," says Wilbeck. "In this case, she didn't stop bleeding, and we did end up giving vitamin K."
In a similar postoperative patient without the blood clots in the lung, it would have been less risky to give the anticoagulants, so this would have been done sooner, explains Wilbeck.
• Know reversal agents and antidotes.
For patients who have taken too much insulin, simple intravenous dextrose will correct the blood sugar, and the patient then must be monitored, says Wilbeck. Warfarin overdoses, on the other hand, can be reversed with an injection to stop the anticoagulation process and stop the bleeding, she says.
Another excellent resource is your hospital's clinical pharmacist, says Wilbeck. "A quick phone call to the pharmacy can most often answer any questions as to what nurses should monitor in regard to ADEs, and also any available antidotes," she says.
• Always assess the patient's airway.
Angiotensin-converting enzyme (ACE) inhibitors, antibiotics, and even some pain medicines may cause a patient to have facial swelling that can compromise the airway, warns Wilbeck. "Depending on the severity of the reaction, airway management may be crucial," she says.
• Teach the patient to prevent future ADEs.
Unintentional overdoses accounted for more than half of severe ADEs in the CDC study. "Emergency nurses can help to ensure patients adhere to the medication regimen prescribed on discharge from the ED," says Budnitz.
Wilbeck remembers a woman who presented with intense itching and welts over her face, neck, and chest after taking a first dose of an antibiotic that she had never taken before. After receiving intravenous diphenhydramine and steroids with close observation, her symptoms resolved.
"With this patient, discharge teaching was crucial," says Wilbeck. "Teaching the patient that this allergy will last longer than one dose of medicine encouraged her to complete all of her steroids and other medications." Tell patients when to seek medical help and which medications to avoid in the future, she advises.
• Make sure the correct medication was dispensed.
ED nurses at Rogue Valley Medical Center checked the medications taken by a bradycardic, hyperglycemic patient and realized that she was accidentally given digoxin instead of her oral diabetic medications. "This fortunately does not happen often, but it can happen," says Heather Freiheit, RN, BSN, EMT-P, clinical manager of emergency services.
• Ask patients if they've been exposed to anything new.
Ask specifically about prescriptive, over-the-counter, and herbal medications, as well as foods, cleaning products, soaps, and perfumes, recommends Jane Sawall, MS, MPH, APRN-BC, CEN, a clinical nurse specialist at Rogue Valley's ED. "Often, patients will forget that they tried a home remedy or purchased a new soap or shampoo," she says.
Reference
- Budnitz DS, Pollock DA, Weidenbach KN, et al. National surveillance of emergency department visits for outpatient adverse drug events. JAMA 2006; 296:1,858-1,866.
Sources
For more information about treating adverse drug events in the ED, contact:
- Dan Budnitz, MD, MPH, CDR, USPHS, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road N.E, Mailstop A-24, Atlanta, GA 30333. Telephone: (404) 639-4096. Fax: (404) 639-4045. E-mail: [email protected].
- Heather Freiheit, RN, BSN, EMT-P, Clinical Manager, Emergency Services, Rogue Valley Medical Center, 2825 E. Barnett Road, Medford, OR 97504. Telephone: (541) 789-7120. E-mail: [email protected].
- Jane Sawall, MPH, APRN-BC, CEN, Clinical Nurse Specialist, Rogue Valley Medical Center, 2825 E. Barnett Road, Medford, OR 97504. Telephone: (541) 789-7194. E-mail: [email protected].
- Jennifer Wilbeck, MSN, APRN, CEN, APRN, CEN, Emergency Department, Centennial Medical Center, 2300 Patterson St., Nashville, TN 37203. Telephone: (615) 322-4195. Fax: (615) 936-0228. E-mail: [email protected].
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