CardioExchange Archive

We welcome Tom Tsai, MD, MSc, to this forum to talk about his article in last week’s JAMA: Contraindicated Medication Use in Dialysis Patients Undergoing Percutaneous Coronary Intervention (JAMA. 302:2458). We asked him our questions, and encourage you to ask yours.

CardioExchange Editors: Your study found that nearly a quarter of dialysis patients undergoing PCI received contraindicated antithrombotic medications. Why do you think this practice exists? 

Tsai: There are practical considerations that make the contraindicated medications easier to administer. For example, enoxaparin is administered either as an IV bolus or SQ injection without the need for a continuous IV drip which is the case for UF heparin when patients are treated for ACS (as was the case with 60% of our study population). Eptifibatide is typically the GPI IIbIIIa of choice for most hospitals and cath labs sans STEMI and is the medication of choice for upstream use. Additionally, from a systems perspective, those clinical pathway pre-printed order sets used in many hospitals to ensure the use of evidence based strategies–a type of ”cook book medicine”–can actually lead to errors if they aren’t sophisticated enough to protect against caveats that make an evidence-based therapy in your average ACS patient an inappropriate therapy in subset of that population, such as dialysis patients.   

CardioExchange Editors: Was this a practice that predominated at certain hospitals or did it occur with the same frequency at most institutions?

Tsai: Certain hospital characteristics were associated with the use of contraindicated antithrombotic use, namely rural location, non-teaching institutions, and lower procedural volumes. Whether this represented a knowledge gap or more frequent use of pre-printed order sets in these institutions or still other factors is unknown.    
 
CardioExchange Editors: What steps do you recommend individuals or institutions take to end this practice? You mention educational efforts, but practically speaking, what should happen quickly?

Tsai: First, institutions that have pre-printed order sets or ACS pathways on their EMR ordering systems should examine them carefully for medication orders that do not account for factors such as dialysis or renal function. It requires an amendment of these order sets and should prompt the review of all other order sets that may be at risk for a similar error. This is low-hanging fruit. More generally, residency/fellowship training programs should have patient safety seminars that focus on the issue of medication errors and patient safety. This study only illustrates a small slice of two larger epidemics in the practice of medicine: (1) the application of clinical-trial data to populations where the agent has not been validated, and (2) the failure to master the litany of contraindications in our ever-growing armamentarium. 

CardioExchange Editors: So we’re very curious to hear from the CardioExchange community: What questions or perspectives do you have? Do practices like this happen at your institution? What insights do you have about avoiding such errors?