Interdisciplinary Systems-Based Intervention to Improve IV Hydration during Parenteral Administration of Acyclovir.

BACKGROUND: Intravenous (IV) hydration is considered a protective factor in reducing the incidence of acyclovir-induced nephrotoxicity. A systems-based review of cases of acyclovir-associated acute kidney injury can be used to examine institution-, care provider-, and task-related factors involved in administering the drug and can serve as a basis for developing a quality improvement intervention to achieve safer administration of acyclovir. OBJECTIVES: To explore the effectiveness of the study institution's inter-disciplinary quality improvement intervention in increasing the dilution of acyclovir before IV administration. METHODS: After conducting a systems-based review for intervention development, a retrospective analysis was undertaken to compare IV administration of acyclovir in the 6-month periods before and after implementation of the intervention. The study population was a sequential sample of all patients over 18 years of age who were seen in the emergency department or admitted to a ward and who received at least one IV dose of acyclovir at the study institution. The primary outcome was the volume in which each acyclovir dose was delivered. The secondary outcomes were the hourly rate of fluid administration, the frequency of an increase in hourly hydration rate, and the incidence of acute kidney injury. RESULTS: Eighty-four patients (44 in the pre-intervention period and 40 in the post-intervention period) received IV acyclovir and had evaluable data for the primary outcome. The median volume in which the acyclovir dose was administered was significantly higher in the post-intervention group (250 mL versus 100 mL, p < 0.001). CONCLUSIONS: In this study, an easily implemented intervention significantly increased the volume of IV fluid administered to patients receiving acyclovir. Adequately powered prospective studies are suggested to investigate the effectiveness of this intervention on the clinically relevant incidence of acyclovir-induced nephrotoxicity.

CONTEXTE: L'hydratation par voie intraveineuse est considérée comme un facteur de protection aidant à réduire l'incidence des cas de néphrotoxicité associés à l'acyclovir. Une analyse de systèmes des cas d'insuffisance rénale aiguë associés à l'acyclovir peut servir à examiner les facteurs liés aux établissements, aux fournisseurs de soins et aux tâches qui touchent l'administration du médicament et à générer ainsi une mesure visant l'amélioration de la qualité qui rendra l'administration d'acyclovir plus sûre. OBJECTIF: Étudier l'efficacité de la mesure interdisciplinaire visant l'amélioration de la qualité qui a été mise en œuvre dans l'établissement de l'étude et qui encourageait à diluer davantage l'acyclovir avant son administration par voie intraveineuse. MÉTHODES: Après avoir procédé à une analyse de systèmes pour générer une mesure d'intervention, une analyse rétrospective a été réalisée afin de comparer l'administration d'acyclovir par voie intraveineuse au cours des six mois précédant et suivant la mise en œuvre de la mesure. La population de l'étude était composée d'un échantillon progressif de tous les patients de plus de 18 ans ayant séjourné aux urgences ou dans un service intra-hospitalier et ayant reçu au moins une dose d'acyclovir par voie intraveineuse dans l'établissement concerné. Le principal paramètre d'évaluation était le volume de liquide contenant chaque dose d'acyclovir administrée. Les paramètres d'évaluation secondaires comprenaient : le débit horaire de liquide administré, la fréquence d'ajustement à la hausse du débit liquidien horaire et la fréquence des cas d'insuffisance rénale aiguë. RÉSULTATS: Quatre-vingt-quatre patients (44 dans la période précédant l'application de la mesure et 40 dans la période la suivant) ont reçu de l'acyclovir par voie intraveineuse et présentaient des données évaluables pour le paramètre principal. Le volume médian avec lequel chaque dose d'acyclovir était administrée était significativement supérieur dans le groupe suivant l'application de la mesure (250 mL contre 100 mL, p < 0,001). CONCLUSIONS: Cette étude montre qu'une mesure facile à mettre en place augmentait de façon significative le volume de liquides intraveineux administré aux patients recevant de l'acyclovir. L'on suggère de réaliser des études prospectives d'une puissance suffisante pour évaluer l'efficacité de cette mesure en ce qui a trait à la fréquence cliniquement significative des cas de néphrotoxicité associés à l'acyclovir.

Lack of increased colonization with vancomycin-resistant enterococci during preferential use of vancomycin for treatment during an outbreak of healthcare-associated Clostridium difficile infection.

OBJECTIVE: To assess whether use of oral vancomycin for treatment during an outbreak of Clostridium difficile infection (CDI) was associated with increased rates of colonization with vancomycin-resistant enterococci (VRE). DESIGN: A retrospective analysis of hospital databases. SETTING: The Jewish General Hospital in Montreal, Quebec, Canada. METHODS: We collected data regarding VRE colonization and CDI from November 1, 2000, through September 30, 2007, during which policies of preferential oral metronidazole or vancomycin treatment were implemented to control an outbreak of CDI. Four periods were considered: period 1, the preoutbreak period when metronidazole was used; period 2, the CDI outbreak period when metronidazole was used; period 3, the postoutbreak period when vancomycin was used; and period 4, the postoutbreak period when metronidazole was used. RESULTS: A total of 2,412 cases of CDI and 425 cases of VRE colonization were identified. The rate of CDI increased significantly during period 2 and decreased to preoutbreak levels during period 3. The rate of VRE also increased during period 2 and decreased during the first 18 months of period 3. A clonal outbreak of cases of VRE (VanA) colonization was observed toward the end of period 3 and into period 4. Excluding the period of the clonal outbreak, there was a strong correlation between the number of cases of CDI and VRE colonization (r=0.736; P=.001) and a negative association between VRE colonization and vancomycin use (r=-0.765; P=.04). CONCLUSIONS: Increased vancomycin use was not associated with an increase in VRE colonization over a 2-year period. Restriction of vancomycin use during CDI outbreaks because of the fear of increasing VRE colonization may not be warranted.

Emergency physician recognition of adverse drug-related events in elder patients presenting to an emergency department.

OBJECTIVES: The authors examined the ability of emergency physicians (EPs) to recognize adverse drug-related events (ADREs) in elder patients presenting to the emergency department (ED). METHODS: This was a prospective observational study of patients at least 65 years of age who presented to the ED. ADREs were identified using a validated, standardized scoring system. EP recognition of ADREs was assessed through physician interview and subsequent chart review. RESULTS: A total of 161 patients were enrolled in the study. Thirty-seven ADREs were identified, which occurred in 26 patients (16.2%; 95% confidence interval [CI] = 10.5% to 22.0%). The treating EPs recognized 51.2% (95% CI = 35.2% to 67.4%) of all ADREs. There was better recognition of those ADREs related to the patient's chief complaint (91%; 95% CI = 74.1% to 100%) as compared with recognition of ADREs that were not associated with the chief complaint (32.1%; 95% CI = 14.8% to 49%). EPs recognized six of seven severe ADREs (85.7%), 13 of 23 moderate ADREs (56.5%; 95% CI = 36.8% to 77%), and none of the mild ADREs. Recognition of ADREs varied with medication class. CONCLUSIONS: EP performance was superior at identifying severe ADREs relating to the patients' chief complaints. However, EP performance was suboptimal with respect to identifying ADREs of lower severity, having missed a significant number of ADREs of moderate severity as well as ones unrelated to the patients' chief complaints. ADRE detection methods need to be developed for the ED to aid EPs in detecting those ADREs that are most likely to be missed.