2. Godzilla Meets the Little Red Hen Or, the Prescribing Cascade Meets the Bedside Observer Johanna Trimble Patient Representative Sponsored by:Community Engagement Advisory Network, Vancouver Coastal Health Authority Member: World Health Organization Patient Safety Champion BC Patient Voices Network Patients for Patient Safety Canada (CPSI)
3. The Characters
5. Sometimes known as…• The Prescribing Cascade• Polypharmacy (stand-alone risk)• Overmedication (dose, treating test)• Too many (9 drugs average in RC, 0-55)
6. The Little Red Hen
7. Sometimes known as…• The family member• The friend• The puzzled visitor• The staff member• The bedside observer
8. Fervid Trimble, the patient
9. Fervid’s admission to the Health Centre• After a ‘flu and dehydration episode, admitted to the Health Centre for a few days recuperation• Instead she became bedridden, confused, delirious, unable to recognize family plus other puzzling symptoms• SSRI anti-depressant had been prescribed• Other drugs had been changed or prescribed
10. Trust your instincts and press for answers Why is this not making sense!??
11. Hmmm, Iwonder if it’s the drugs?
12. Why don’t we ask questions of the professionals?• “They’re the professionals, they must know” – Wrong! they know medicine -- you know the patient• “They’re busy and we’ll annoy them” – Wrong! this is your loved one, make an appointment!• “We’ll make them mad and they’ll call us difficult and take it out on her” – Wrong! Do your research, be clear, respectful and persistent• “I’m part of the team!” – RIGHT! You can help because you’re nearby observing, comparing against baseline and asking questions.
13. Fervid’s “family care team”Johanna, Dale, Fervid and Kathie
18. UTI or Serotonin Syndrome?• Fervid was repeatedly prescribed antibiotics for urinary tract infections• Delirium, elevation of white blood cells, frequent urination and fever of SS mistaken for a UTI• Now we’ve got lots of antibiotics prescribed and eventually we’re going to see c. difficile
19. Treating UTI’s and c. difficile• Starting to be addressed in BC• Both VCH and Fraser Health are working on improving UTI treatment protocols to address antibiotic overuse & c. difficile
20. Serotonin Syndrome• Symptoms include cognitive, autonomic and somatic effects & range from barely perceptible to fatal• Clonus, hyperreflexia and flushing are the most specific signs.• Fervid was delirious, making unexplained repetitive arm movements (clonus), sometimes “asleep” and we couldn’t wake her
21. Fervid’s Prescribing CascadeUnrecognized drug adverse effects,symptoms of Serotonin Syndrome,were treated with additional drugsas if these symptoms were newconditions.
22. DIGOXIN!? Butthe rapid heartbeat wascaused by thethe drugs...!?
23. A Common Mistake? Fervid’s Cascade:• SS onset can be either dramatic or insidious making it harder to recognize• Symptoms of SS were treated as a common UTI (with nitrofurantoin, Beer’s list antibiotic)• Rapid heartbeat, symptom of SS, was treated with heart medication digoxin (Beer’s list)• Delusions, hallucinations, confusion were about to be addressed using Aricept• The family declined it and any other prescriptions unless consulted first.
24. ARICEPT!? But this deliriumwas caused by the drugs... What the…??
25. A picture is worth a thousand words… Over-medicated After the “drugectomy”
26. Being bedridden resulted in loss of function,Fervid could not return to independent living!
27. Here wegoagain…
28. Yes, it can happen twice…• 3 years later Fervid was admitted to hospital with a stomach bleed• Several new drugs prescribed in hospital• On return, confusion and delirium ensued• A new doctor prescribed remeron (serotonergic)• Symptoms of SS started JUST like 3 years ago• Antibiotics were prescribed “for UTI” -- again• Remeron was stopped and Fervid quickly returned to normal
29. Polypharmacy & c. difficile• Fervid had many antibiotic treatments for UTI’s or respiratory infections• Probably other residents did too• 5 other residents had c. difficile• Cleaning & infection protocols substandard or inconsistent• Frequent transfer of staff and patients• 5 or 6 courses of vancomycin weakened Fervid greatly• No fecal transplant offered except in Australia
30. Fecal transplant in 2008? (only in Australia) Now, in 2013, it is in the news:• The US Centers for Disease Control has issued an urgent plea for fecal transplant donors after the recent studies show its efficacy• After much deliberation, CDC Vice- Director Dr. Steven Gerrard has announced that the drive for fecal donors is being launched with the slogan: “Save a life. Get your shit together.”
31. C. difficile• Fervid may not have died OF c. diff but she was greatly weakened and died WITH c. difficile• The important factor is the overuse of antibiotics and the growing resistance of organisms
32. Let’s DOSOMETHINGaboutpolypharmacy!
33. BC Polypharmacy Initiative (Shared Care)www.bcma.org/polypharmacy-initiative
34. “It’s (about) quality of life…for my residents. Ive seendramatic differences in the quality of their life when theBURDEN of their medication is reduced...”
35. Dedicated to Fervid Trimble 1917 - 2008 A picnic in the garden with Fervid