Interdisciplinary videoconference model for identifying potential adverse transition of care events following hospital discharge to postacute care.

Discharge from hospitals to postacute care settings is a vulnerable time for many older adults, when they may be at increased risk for errors occurring in their care. We developed the Extension for Community Healthcare Outcomes-Care Transitions (ECHO-CT) programme in an effort to mitigate these risks through a mulitdisciplinary, educational, case-based teleconference between hospital and skilled nursing facility providers. The programme was implemented in both academic and community hospitals. Through weekly sessions, patients discharged from the hospital were discussed, clinical concerns addressed, errors in care identified and plans were made for remediation. A total of 1432 discussions occurred for 1326 patients. The aim of this study was to identify errors occurring in the postdischarge period and factors that predict an increased risk of experiencing an error. In 435 discussions, an issue was identified that required further discussion (known as a transition of care event), and the majority of these were related to medications. In 14.7% of all discussions, a medical error, defined as 'any preventable event that may cause or lead to inappropriate medical care or patient harm', was identified. We found that errors were more likely to occur for patients discharged from surgical services or the emergency department (as compared with medical services) and were less likely to occur for patients who were discharged in the morning. This study shows that a number of errors may be detected in the postdischarge period, and the ECHO-CT programme provides a mechanism for identifying and mitigating these events. Furthermore, it suggests that discharging service and time of day may be associated with risk of error in the discharge period, thereby suggesting potential areas of focus for future interventions.

A Retrospective Comparison of the Effectiveness and Safety of Intravenous Olanzapine Versus Intravenous Haloperidol for Agitation in Adult Intensive Care Unit Patients.

OBJECTIVE: Intravenous (IV) olanzapine could be an alternative to first-generation antipsychotics for the management of agitation in intensive care unit (ICU) patients. We compared the effectiveness and safety of IV olanzapine to IV haloperidol for agitation management in adult patients in the ICU at a tertiary academic medical center. METHODS: A retrospective cohort study was conducted. The primary outcome was the proportion of patients who achieved a Richmond Agitation Sedation Scale (RASS) score of < +1 within 4 hours of IV olanzapine or IV haloperidol administration. Secondary outcomes included the proportion of patients who required rescue medications for agitation within 4 hours of initial IV olanzapine or IV haloperidol administration, incidence of adverse events and ICU length of stay. RESULTS: In the 192 patient analytic cohort, there was no difference in the proportion of patients who achieved a RASS score of < +1 within 4 hours of receiving IV olanzapine or IV haloperidol (49% vs. 42%, p = 0.31). Patients in the IV haloperidol group were more likely to receive rescue medications (28% vs 55%, p < 0.01). There was no difference in the incidence of respiratory events or hypotension between IV olanzapine and IV haloperidol. Patients in the IV olanzapine group experienced more bradycardia (11% vs. 3%, p = 0.04) and somnolence (9% vs. 1%, p = 0.02) compared to the IV haloperidol group. Patients in the IV olanzapine group had a longer median ICU length of stay (7.5 days vs. 5 days, p = 0.04). CONCLUSION: In this retrospective cohort study, there was no difference in the effectiveness of IV olanzapine compared to IV haloperidol for the management of agitation. IV olanzapine was associated with an increased incidence of bradycardia and somnolence.

Clozapine-induced cardiomyopathy and myocarditis monitoring: A systematic review.

The use of clozapine requires monitoring the absolute neutrophil count because of the risk of agranulocytosis, but other potentially fatal adverse events associated with clozapine (specifically, myocarditis and cardiomyopathy) do not have mandatory procedures. We performed a systematic review of English-language articles to synthesize an evidence-based approach for myocarditis and cardiomyopathy monitoring. Articles published from January 1988 through February 2017 were identified through a search of Ovid MEDLINE, Ovid Embase, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus, and Google Scholar. Selected articles were required to relate to myocarditis or cardiomyopathy in humans from exposure to clozapine. A total of 144 articles were included. Recommendations varied widely. Some authors recommended baseline laboratory monitoring, with or without follow-up testing, for C-reactive protein, creatine kinase MB, and troponin. Electrocardiography was commonly recommended, and echocardiography was less commonly recommended. The expense of monitoring was a consideration. A unanimous recommendation was to stop the use of clozapine and seek a cardiovascular consultation if myocarditis or cardiomyopathy is suspected. Although there is general agreement on which tests to perform for confirming myocarditis and cardiomyopathy, preemptive screening for these clozapine-induced conditions is controversial, and cost and barriers for the use of clozapine are concerns. For asymptomatic patients receiving clozapine, testing could include baseline electrocardiography, echocardiography as part of a cardiac consultation if patients have cardiac disease or risk factors, and monitoring of C-reactive protein and troponin as indicated.