Evidence based development of bedside clinical drug rules for surgical patients
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Background Surgical adverse events constitute a considerable problem. More than half of in-hospital adverse events are related to a surgical procedure. Medication related events are frequent and partly preventable. Due to the complexity and multidisciplinary nature of the surgical process, patients are at risk for drug related problems. Consistent drug management throughout the process is needed. Objective The aim of this study was to develop an evidence—based bedside tool for drug management decisions during the pre- and postoperative phase of the surgical pathway. Setting Tool development study performed in an academic medical centre in the Netherlands involving an expert panel consisting of a surgeon, a clinical pharmacist and a pharmacologist, all experienced in quality improvement. Method Relevant medication related problems and critical pharmacotherapeutic decision steps in the surgical process were identified and prioritised by a team of experts. The final selection comprised undesirable effects or unintended outcomes related to surgery (e.g. pain, infection) and comorbidity related hazards (e.g. diabetes, cardiovascular diseases). To guide patient management, a list of bedside surgical drug rules was developed using international evidence-based guidelines. Main outcome measure 55 bedside drug rules on 6 drug categories, specifically important for surgical practice, were developed: pain, respiration, infection, diabetes, cardiovascular diseases and anticoagulation. Results A total of 29 evidence—based guidelines were used to develop the Bedside Surgical Drug Rules tool. This tool consist of practical tables covering management regarding (1) the most commonly used drug categories during surgery, (2) comorbidities that require dosing adjustments and, (3) contra-indicated drugs in the perioperative period. Conclusion An evidence-based approach provides a practical basis for the development of a bedside tool to alert and assist the care providers in their drug management decisions along the surgical pathway.
KeywordsAdverse drug event Drug rules Medication related harm Surgery Tool development The Netherlands
We are very grateful for the cooperation and input of the clinical pharmacists, the pharmacologists and the consulting surgeons for their input in the development of the surgical drug rules.
This study was made possible by funding of ZonMw, The Netherlands Organization for Health Research and Development (Project Number 170882706).
Conflicts of interest
- 18.Expert Group On Safe Medication Practices: Creation of a better medication safety culture in Europe: Building up safe medication practices. Strasbourg, France: 2006.Google Scholar
- 19.Macintyre PE, Schug SA, Scott DA, Visser EJ, Walker SM; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute pain management: scientific evidence. 3rd ed. Melbourne: ANZCA & FPM; 2010.Google Scholar
- 20.NHS Quality Improvement Scotland 2004 Postoperative Pain Management. ISBN: 1-84404-285-7 First published June 2004.Google Scholar
- 21.NHS-NPC Cardiovascular and gastrointestinal safety of NSAIDs. MeReC extra issue no 30; 2007.Google Scholar
- 22.NICE CKS. NSAIDs—prescribing issues. www.cks.nice.org.uk/nsaids-prescribing-issues.
- 23.Doshi D, Foex B, Body R, Mackway-Jones K. Guideline for the management of acute allergic reaction. In: GEMNET 2009.Google Scholar
- 24.Celli BR, MacNee W, Agusti A, Anzueto A, Berg B, Buist AS, Calverley PMA, Chavannes N, Dillard T, Fahy B, Fein A, Heffner J, Lareau S, Meek P, Martinez F, McNicholas W, Muris J, Austegard E, Pauwels R, Rennard S, Rossi A, Siafakas N, Tiep B, Vestbo J, Wouters E, ZuWallack R. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004 Jun;23(6):932–46.Google Scholar
- 25.Haeck PC, Swanson JA, Iverson RE, Lynch DJ, ASPS Patient Safety Committee. Evidence-based patient safety advisory: patient assessment and prevention of pulmonary side effects in surgery. Part 2. Patient and procedural risk factors. Plast Reconstr Surg. 2009;124(4 Suppl):57S–67S.Google Scholar
- 26.Haeck PC, Swanson JA, Iverson RE, Lynch DJ, ASPS Patient Safety Committee. Evidence-based patient safety advisory: patient assessment and prevention of pulmonary side effects in surgery. Part 1. Obstructive sleep apnea and obstructive lung disease. Plast Reconstr Surg. 2009;124(4 Suppl):45S–56S.Google Scholar
- 27.Surgical site infection: Prevention and treatment of surgical site infection. In: National Collaborating Centre for Women’s and Children’s health. Clinical Guideline 2008. ISBN: 978-1-904752-69-1.Google Scholar
- 28.Perioperative Protocol. In: Institute for Clinical Systems Improvement. Guidelines 2010. https://www.icsi.org/guidelines__more/catalog_guidelines_and_more/catalog_guidelines/catalog_patient_safetyreliability_guidelines/perioperative/.
- 29.Antibiotic Prophylaxis in Surgery. Adapted from Scottish Intercollegiate Guidelines Network. SIGN 104: A national practical guideline. Edinburgh: SIGN.Google Scholar
- 30.Steinberg JP, Braun BI, Hellinger WC, Kusek L, Bozikis MR, Bush AJ, et al, Trial to Reduce Antimicrobial Prophylaxis Errors (TRAPE) Study Group. Timing of antimicrobial prophylaxis and the risk of surgical site infections: results from the Trial to Reduce Antimicrobial Prophylaxis Errors. Ann Surg. 2009;250(1):10–6.Google Scholar
- 31.Kao LS, Meeks D, Moyer VA, Lally KP. Peri-operative glycaemic control regimens for preventing surgical site infections in adults. Cochrane Database Syst Rev. 2009;8(3):CD006806.Google Scholar
- 33.Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al., American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, American Heart Association Council on Cardiovascular Disease in the Young, American Heart Association Council on Clinical Cardiology, American Heart Association Council on Cardiovascular Surgery and Anesthesia, Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007;116(15):1736–54. Epub 2007 Apr 19. Erratum in: Circulation. 2007;116(15):e376–7.Google Scholar
- 34.Prevention of surgical site infections. In: Prevention and Control of healthcare associated infections in Massachusetts, part-1: Final recommendations of the expert panel; JSI research and training institute; 2008;61–8.Google Scholar
- 35.National electronic Library for Medicines http://www.diabetes.org.uk/Documents/Professionals/Reportsandstatistics/Managementofadultswithdiabetesundergoingsurgeryandelectiveprocedures-improvingstandards.pdf. NHS Diabetes. 2011.
- 36.Joshi GP, Chung F, Vann MA, Ahmad S, Gan TJ, Goulson DT, et al.; Society for Ambulatory Anesthesia. Society for Ambulatory Anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth Analg. 2010;111(6):1378–87.Google Scholar
- 37.Watson B, Smith I, Jennings A, Wilson SF. Day surgery & the diabetic patient. Guidelines for the assessment and management of diabetes in day surgery patients. In: British association of day surgery. Working group 2nd Edition 2004.Google Scholar
- 38.Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al., 2006 Writing Committee Members, American College of Cardiology/American Heart Association Task Force. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008;118(15):e523–61.Google Scholar
- 39.Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al., ESC Committee for Practice Guidelines. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J. 2009;30(19):2369–413.Google Scholar
- 40.American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine, Society for Vascular Surgery, Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, et al. ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol. 2009;54(22):e13–e118.Google Scholar
- 41.Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery; European Society of Cardiology (ESC), Poldermans D, Bax JJ, Boersma E, De Hert S, Eeckhout E, Fowkes G, et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery. Eur Heart J. 2009;30(22):2769–812.Google Scholar
- 45.Douketis JD, Berger PB, Dunn AS, Jaffer AK, Spyropoulos AC, Becker RC, et al. American College of Chest Physicians. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(Suppl):299S–339S.Google Scholar
- 46.O’Riordan JM, Margey RJ, Blake G, O’Connell PR. Antiplatelet agents in the perioperative period. Arch Surg. 2009;144(1):69–76; discussion 76.Google Scholar
- 47.Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, et al. American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):381S–453S.Google Scholar
- 52.Hoonhout LH, de Bruijne MC, Wagner C, Asscheman H, van der Wal G, van Tulder MW. Nature, occurrence and consequences of medication-related adverse events during hospitalization: a retrospective chart review in the Netherlands. Drug Saf. 2010 Oct 1;33(10):853–64.Google Scholar
- 55.Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al.; Harvard Medical Practice Study I. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. 1991. Qual Saf Health Care. 2004;13(2):145–51; discussion 151–2.Google Scholar