Samson, Kurt

doi: 10.1097/01.NT.0000521707.42281.48

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A retrospective, population-based study found that 11 adverse events (AEs) occurred for every 100 admissions for neurological conditions in hospitals in Canada. Outside experts pointed to system errors and problems with communication especially in handing off patients to other doctors as likely causes of problems.

Nearly 50 percent of adverse events that occur in hospitals are preventable, experts in patient safety told Neurology Today, which is why new data from a Canadian study showing that patients with neurological conditions had significantly more complications that those in the general hospital population are disturbing. The report, they said, speaks to the need for evidence-based best practices that better promote hospital safety.

Published in the June 14 online edition of Neurology, the retrospective, population-based study looked at discharge data for 177,612 pediatric and adult patients with neurological conditions from 115 Alberta health care facilities from 2009 to 2015. The report found 11 adverse events (AEs) occurred for every 100 admissions for neurological conditions this, compared with an earlier (2004) Canadian Adverse Events Study that found 7.5 AEs per 100 patients admitted for any condition at a representative sample of Canadian hospitals. [For more detailed findings, see Data on Adverse Events in Neurological Conditions.]

In the new study, AEs occurred most often in patients with spinal cord injury, stroke, Alzheimer disease and related dementia (ADRD), and traumatic brain injury (TBI). Infections and respiratory complications were the most common AEs except in brain tumor and spinal cord injury patients. Patients with spinal cord injury had 5.4 times greater odds of an AE compared to those with other neurological conditions. Adverse events were also more common in older patients and in those with higher comorbidity scores.

Neurological patients with AEs had 2.4 times the odds of dying compared to those without AEs, said lead author Nathalie Jett, MD, professor of neurology and community health sciences at the University of Calgary Cumming School of Medicine and Canada Research Chair in Neurological Health Services Research at the Hotchkiss Brain Institute & O'Brien Institute for Public Health.

Our findings support previous reports that hospitalized patients are at great risk for AEs, with higher estimates reported in this neurological population compared to the prior Canadian study in the general hospital population.

She noted that a number other international studies have reported that around 37 percent to 51 percent of AEs in hospital patients are preventable.

There are several of steps that can be taken to minimize the risk of AEs in neurological patients such as determining fall risk on admission, avoiding sedating medications, assessing swallowing function early, implementing deep venous thrombosis prophylaxis when necessary and doing careful medication reconciliation so patients do not miss any critical drugs on admission, noted Dr. Jett.

The time is right to carefully explore the reasons for these AEs and to develop and implement standardized clinical care pathways to reduce the rates of AEs for hospitalized neurological patients, she said.

The study authors assessed adverse events from discharge data for patients with one of nine neurological conditions: ADRD, brain tumor, epilepsy, motor neuron disease, multiple sclerosis, parkinsonism/Parkinson disease, spinal cord injury, traumatic brain injury, and stroke.

The researchers included 15 AEs in 18 categories: infections; ulcers; endocrinological AEs; venous thromboembolic; cardiac; respiratory; hemorrhagic; drug-related; fluid-related; obstetrical; fetal; surgical; traumatic; anesthetic; delirium-related; other CNS issues; gastrointestinal; and falls.

Among spinal cord patients, AEs occurred in 39.4 out of every 100 admissions, and among these patients, surgery-related AEs accounted for the highest proportion of AEs followed by infections and respiratory-related AEs (24.4 percent, 23.9 percent, and 16.7 percent, respectively).

The reason for the high proportion of AEs in those with a spinal cord injury is likely multifactorial, Dr. Jett told Neurology Today. Spinal cord patients were more likely to have a surgical AE, she noted, adding that these patients have more procedures and interventions in the hospital.

Commenting on the study, Don B. Smith, MD, FAAN, clinical professor of neurology and director of the Colorado Neurological Institute at the University of Colorado Health Sciences Center, said: The adverse events reported here are clinically significant. Neurologists will rightly be concerned that this paper supports previous reports that neurological patients are more frequently affected by AEs than are non-neurological patients.

The paper is a valuable contribution to the patient safety movement by offering insights into the frequency and types of AEs that affect neurological patients, he said. If confirmed by other studies, the findings may help to stratify and specify the types of AE risks across different types of neurological patients, and such information could be valuable in predicting and preventing adverse events.

Dr. Smith cautioned, however, that the paper was a retrospective, observational study that used ICD-10-CA codes to identify both neurological diagnoses and adverse events. The latter is something that has not yet been validated, and the sensitivity and specificity of administrative data in identifying AEs are not precisely known, he told Neurology Today. It is unfortunate that the researchers were not able to determine which of these adverse events were preventable, he added.

There are many strategies to mitigate the risk of adverse events in hospitals, but limited evidence of their effectiveness, Dr. Smith noted. Preventable harm is usually due to a system failure rather than the actions of individual health care providers. One of the most important root causes is a failure in communication, something that is particularly prone to occur during transitions of care. As a starting point for exploring this issue, I would recommend the AAN's NeuroLearn courses on patient safety.

Janis Miyasaki, MD, FAAN, professor and director of the Movement Disorders Program at the University of Alberta, in Edmonton, noted that throughout Canada the nursing ratios vary across hospitals, regions, and provinces.

In addition, she said, registered nurses have increasingly been replaced by licensed practical nurses.In some hospitals neurology patients are deemed to be lighter care than other groups of patients.

She told Neurology Today that access to neurologists and neurosurgeons could be relevant as a trend, as well.

There are approximately 775 neurologists in Canada compared to [approximately] 14,000 in the US, and the Canadian population is approximately a 9:1 ratio to US, so the neurology workforce is certainly an issue throughout North America.

The findings are pretty generalizable to hospitals in the United States, and are not surprising, said Eric J. Thomas, MD, MPH, professor and director of the University of Texas Houston-Memorial Hermann Center for Healthcare Quality and Safety. Certainly, these results are reason for more focus on improvement, he said.

Although there are evidence-based guidelines that, if followed consistently, might prevent many of these AEs, especially for stroke, best practices are lacking, he told Neurology Today.

Dr. Thomas noted that the study did not address the effect of long MD trainee hours spent on the ward or transitions of care from one shift to another. He said these factors might play a role in higher AEs in patients, adding that other studies have found that increased numbers of shifts, with concurrent increases in handoffs, increase the risk for adverse events.

The solution is not necessarily to make clinicians work longer and thereby reduce handoffs, but rather to improve the way handoffs are conducted and to improve the information in electronic health records, he said.

An important first step is to recognize that AEs among neurological patients are most often the product of multiple failures at various levels within the system of care, rather than at one person or level, said John C. Probasco, MD, assistant professor and medical director of the Inpatient General Neurology Service at Johns Hopkins Hospital in Baltimore.

With that in mind, he said, it is most important to engage all members of the care team in monitoring and reporting events, as well as having a system in place for making such reports. Reporting should include everything from near-misses to the most harmful events. A system for report review is also needed to address the specific event as well as to help identify areas for improvement to prevent future events.

In addition, care team members should be engaged in developing, implementing, and monitoring the impact of any AE interventions.

Finally, it is important to provide feedback to care team members that their report has been noted and steps are being taken to address opportunities or challenges they have identified, ideally with their involvement. This model can be applied not only at the hospital or health system level but at the level of care units and provider teams.

Dr. Probasco agreed with Dr. Thomas that shift length and frequency put both neurologists in training and in practice at risk for cognitive and emotional fatigue, a set-up for AEs to occur.

Sound and consistent sign-out practices are one demonstrated and practical way to reduce communication failures at the point of care transition, he said. Overall, a balance must be struck between the risks posed by shift length and frequency with those posed by care transitions.

* Infections were highest among brain tumor patients (23.6 percent), while surgery-related AEs accounted for a higher proportion of AEs than did respiratory-related AEs (20.0 percent vs 12.1 percent).

* Hemorrhagic issues accounted for 13.5 percent more than respiratory problems.

* Patients under 18 years old with a spinal cord injury or a traumatic brain injury had fewer AEs than those who were 18 or older, while younger patients with a stroke or motor neuron disease had more AEs than those who were older.

* Admissions with ADRD had the greatest proportion of comorbidities, closely followed by stroke and brain tumor. The co-occurrence of neurological conditions was 7 percent, with the highest proportion in patients with PD (32.5 percent) and the lowest in those with multiple sclerosis (8.1 percent).

* The median length of stay was eight days and was highest for spinal cord injuries, ADRD, and parkinsonism/Parkinson disease, while the overall mortality was 9.1 per 100 admissions, and was highest among those with motor neuron disease at 18 per 100 admissions.

* Those with ADRD represented the higher proportion of admitted patients (37 percent), followed by stroke (24.4 percent) and epilepsy (12.9 percent), and of all admissions, 6.9 percent were re-admissions. Readmissions were higher in patients with motor neuron disease, brain tumor, and ADRD.

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Adverse Events Reported to Be Higher for Neurological In-Patients in Canadian Study: What Can Be Done? - LWW Journals