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CRITICAL INCIDENTS AMONGST 10033 ACUTE PAIN PATIENTS

James E Paul, MSc MD FRCPC^*, Monakshi Sawhney, MN ACNP, W. Scott Beattie, MD FRCPC PhD and Richard F McLean, MD FRCPC^*

^* Department of Anesthesia, Hamilton Health Sciences, McMaster University, Hamilton, Ontario;
Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Ontario

INTRODUCTION:

The purpose of this study was to determine the incidence of notable events and serious side effects that could lead to patient morbidity or mortality (critical incidents) amongst APS patients in four academic hospitals in Canada.

METHODS:

This was a prospective cohort study. A computerized clinical database (APS Manager) was designed to capture relevant outcomes from APS patients, including: baseline demographics, surgery, acute pain treatment, visit information, and critical incidents. The database was installed in three hospitals in Hamilton in February 2002 and in the Toronto General Hospital in March 2003. Acute pain nurses, who rounded on the patients daily from Monday to Friday, collected data prospectively. Critical incidents that occurred on weekends or holidays were investigated retrospectively. Data was extracted in January 2004 for analysis. Percentages were calculated from total enrollments except for epidural related events (abscess and hematoma).

RESULTS:

A total of 10033 patients were enrolled representing 15673 patient visits for all 4 hospitals. These patients were treated with 7490 PCAs, 4300 epidurals, 65 intrathecal catheters, 21 continuous nerve blocks and 261 adjunctive analgesics (non-PCA narcotics or NSAIDs). The number and percentage of critical incidents are shown in Table 1.

Overall McMaster University Henderson General Hamilton General Toronto General Number of patient enrollments 10033 2639 3314 1886 2194 Days of data collection 695 658 695 645 312 Critical Incidents Severe hypotension 137 (1.37%) 18 (0.94%) 31 (.94%) 74 (3.98%) 15 (0.53%) Respiratory depression 61 (0.61%) 34 (1.21%) 8 (0.24%) 11 (.58%) 8 (0.28%) Death 3 (0.03%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 3 (0.11%) Cardiac arrest 3 (0.03%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 3 (0.11%) Unresponsive 2 (0.02%) 1 (0.04%) 0 (0.00%) 0 (0.00%) 1 (0.04%) Epidural abscess 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) Spinal hematoma 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) 0 (0.00%) Error in pump programming 19 (0.19%) 4 (0.02%) 0 (0.00%) 9 (0.48%) 7 (0.25%) Severe hyptension – SBP 80 mmHg Respiratory depression – respiratory rate < or requirement of naloxone for resuscitation

DISCUSSION:

Overall, a critical incident occurred in 1 in out of every 44 patients. Severe hypotension, respiratory depression and pump programming errors were the most common events. In order to collect relevant data on rare APS outcomes it is necessary for multiple sites to collaborate in their data collection. Although the pain treatments employed by Acute Pain Services have advanced the quality of analgesia therapy it is important to note that there is risk associated with them. Further research is ongoing to ascertain the risk factors for critical incidents.

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