Corinne's main research program evolved from two pilot studies: (1) Adverse Drug Events in Elderly Presenting to an Emergency Department (ED), (Hohl, 2001) was a retrospective study demonstrating that adverse drug events accounted for 10.6% of the ED visits made be the elderly, a proportion higher than previously thought; and (2) Emergency Physician Recognition of Adverse Drug Events (Hohl, 2005) showed that emergency physicians missed half of clinically significant adverse drug events in this patient population, indicating that many patients received inappropriate emergency care because adverse drug events were misdiagnosed. Since these pilot studies, we have secured over $2.3M in funding for our work on adverse drug events. The following studies form the basis of our current work.
The Drug-Related Visit Study (Zed, 2008): Our team’s first large prospective study (n = 1017) confirmed our previous results by showing that adverse drug events were among the most common reasons for adult ED visits to a tertiary-care centre. Adverse drug events caused 12% of ED visits.
Emergency Physician Attribution of Adverse Drug Events to Medication-Related Problems (Hohl, 2010): This prospective study (n = 944) confirmed the results of our 2005 pilot study by showing that physicians identified only 61% of adverse drug events in ED patients, indicating a real need for systematic screening tools that could be implemented into clinical practice to improve patient care.
Outcomes of Patients Presenting to the ED with an Adverse Drug Event (Hohl, 2011): This study (n = 1000) showed that patients diagnosed with adverse drug events in the ED had worse health outcomes than did patients presenting to the ED for other reasons. After adjustment for known confounders, patients with adverse drug events used significantly more inpatient and outpatient health services and incurred almost double the cost compared to other patients, indicating that translational research must focus on quality improvement and preventative efforts in this patient population.
Derivation of a Clinical Decision Rule to Identify Patients at Risk of Drug-Related Morbidity in the ED (Hohl, 2012): In this phase I, prospective, multi-centre, clinical decision rule derivation study (n = 1591), we derived two highly sensitive and specific clinical decision rules, consisting of variables that can easily be collected by ED triage nurses (e.g., presence of comorbid conditions, patient age, etc.). Based on data from derivation, if ED triage nurses were to apply the criteria to patients presenting to the ED, 27% of patients would be identified as high-risk and referred to a pharmacist for medication review, allowing pharmacists to focus on high-risk patients who are most likely to benefit from medication review. Based on derivation, implementation of the ADE clinical decision rule would increase the identification of ADEs from the present 61% to over 90%. This paper was awarded the 2011 Best Paper Award at the American College of Emergency Physician’s conference.
Implementation of an ADE Screening Strategy: A Demonstration Project (ongoing): In July 2011, we received funding from the BC Ministry of Health, and the Vancouver Coastal Health Authority to pilot and evaluate an ADE Screening Strategy in three EDs. The goal is to improve the recognition of ADEs in the ED by introducing the ADE clinical decision rule (described above) at triage, allowing nurses to identify high-risk patients to refer them to pharmacists for medication review. The main objective is to evaluate the impact of implementing the ADE Screening Strategy on clinical care processes, ADE identification and health outcomes. Secondary objectives include evaluating its impact on health services use and cost. We are using a controlled, non-randomized trial design and focusing initially on process outcome measures to ensure that the intervention was successfully implemented, and will subsequently focus on health outcome measures. We are presently mid-way through data collection. To date, triage nurses at three sites in the BC Lower Mainland have screened over 82,000 ED patients using the clinical decision rule to date. Of these, 28% were deemed to be at high-risk for an ADE. Among high-risk patients, pharmacists found and treated ADEs in 32%. Preliminary data indicate that the intervention is feasible, and increases the identification of ADEs. Final results will be available in 2013.
Developing ADE Reporting Fields in PharmaNet to Improve Patient Care and Health Data: Optimizing the health benefits of medications while limiting their potential for harm is a public health priority. Yet, in clinical practice, serious ADEs to outpatient medications are not effectively communicated between healthcare providers or across healthcare sectors. As a result, healthcare providers frequently re-expose patients to culprit medications, and fully 30% of ADEs resulting in hospital admission recur over an average time span of only 300 days. In research and decision-making, high-quality data on ADEs are lacking, undermining efforts in quality improvement, drug safety and effectiveness research, and post-market surveillance. Our objective is to develop and implement a new electronic ADE-reporting platform in PharmaNet, BC’s medication information system to: (1) meet the information needs of clinicians by enabling better documentation and communication of ADEs between care providers and across healthcare sectors; and (2) provide high-quality patient-level data about ADEs to outpatient medications to address an identified gap in health data which undermines evidence-based decision-making. In Step 1, we will map the workflow in emergency departments to determine how a new electronic ADE reporting platform in PharmaNet can best be integrated into the existing work patterns of care providers. In Step 2, we will create a minimum required dataset for ADE reporting, by reviewing the literature and by conducting interviews and focus groups with knowledge users, researchers and decision-makers. In Step 3, we will test and optimize a paper-based method of ADE reporting. We will then develop and introduce an electronic version in PharmaNet. We will develop an ADE display screen for information retrieval and incorporate computerized alerts when attempts are made to re-prescribe or re-dispense culprit medications. In Step 4, we will evaluate the completeness of ADE reporting, and the data quality within the reports. The new ADE reporting platform will be the first to integrate the reporting and retrieval of ADE information into a provincial medication information system during the process of clinical care. By supporting the clinical decision needs of care providers, this project has a strong potential to have an immediate impact on clinical practice. By supporting the data needs of knowledge users and decision makers, this project has the potential to influence health programs and policy decisions that could lead to changes in health outcomes, health resource use and cost.
- Academic emergency medicine : official journal of the Society for Academic Emergency Medicine - 2012, Jun 12
- Annals of emergency medicine - 2011, Aug 29
- Annals of emergency medicine - 2010, Jul 20
- Annals of emergency medicine - 2010, May 24
- Academic emergency medicine : official journal of the Society for Academic Emergency Medicine - 2008, Jan 23