Prospective validation of clinical criteria to identify emergency department patients at high risk for adverse drug events

Abstract

Objectives

Adverse drug events cause or contribute to one in nine emergency department presentations in North America, and are often misdiagnosed. Emergency departments have insufficient clinical pharmacists to complete medication reviews in all incoming patients, even though pharmacist-led medications reviews have been associated with improved health outcomes. Our objective was to validate clinical decision rules to identify patients presenting with adverse drug events so they could be prioritized for pharmacist-led medication review.

Methods

This multicentre, prospective study was conducted in two tertiary and one community hospital in Canada. We enrolled 1529 adults presenting to emergency departments over 12 months. We applied two clinical decision rules and collected baseline variables prior to assessments by clinical pharmacists and physicians. We compared the physician and pharmacist diagnoses with the decision rule results. The primary outcome was a moderate or severe adverse drug event, defined as an unintended and harmful event related to medication use or misuse, which required a change in medical therapy, diagnostic testing, consultation, or admission. An independent committee adjudicated uncertain and discordant cases. We calculated the diagnostic accuracy of both rules.

Results

Among 1529 patients, 184 (12.0%) were diagnosed with an adverse drug event. Rule 1 contained the variables (i) having a pre-existing medical condition or having taken antibiotics within one week, and (ii) age >80 or having a medication change within 28 days. They had a sensitivity of 91.3% (95%CI: 86.3 to 95.0%) and a specificity of 37.9% (95%CI: 35.3 to 40.6%) for adverse drug events.

Conclusions

Our study validated clinical decision rules that can be applied by clinical pharmacists to limit the number of patients requiring medication review, while identifying the majority of patients presenting with clinically significant adverse drug events.

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