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Alarm Fatigue

I missed a drug interaction warning the other day when I prescribed a sulfa antibiotic to Barton, a COPD patient who is also taking dofetilide, an uncommon antiarrhythmic.

The pharmacy called me to question the prescription, and I quickly changed it to a cephalosporin.

The big red warning had popped up on my computer screen, but I x-ed it away with my right thumb on the trackball without reading the warning. Quite honestly, I am so used to getting irrelevant warnings that it has become a reflex to bring the cursor to the spot where I can make the warning go away after a quick glance at it. Even though I have chosen the setting “Pop up drug interaction window only when the interaction is severe”, I get the pop up with almost every prescription.

Today I went back to Barton’s chart and looked at his interaction screen.

With the Bactrim DS no longer there, the first of the red boxes was a major interaction between his 81 mg aspirin and his Pradaxa (dabigatran) – two blood thinners are more likely to make you bleed than one. That is basic knowledge, even common sense.

The next red box was a moderate interaction between his baby aspirin and his lisinopril. Theoretically, higher doses of NSAIDs can interfere with the blood pressure lowering properties of ACE inhibitors. That is very basic knowledge, too.

The third red box, another moderate interaction, was between the aspirin and his steroid-bronchodilator inhaler. Theoretically, steroids and aspirin can increase the risk for stomach irritation and supposedly, the pharmacologic effect of aspirin may be decreased by the inhaler.

After these came several warnings labeled “extreme caution” and some that were “not recommended”. The scrolling seemed endless, so I printed out the warnings instead. They filled eight pages. I counted 61 “extreme caution” warnings, from metoprolol and diabetes to the poor man’s steroid-antifungal cream and his diabetes. Beta blockers can, at least theoretically, decrease the tremors and other warning symptoms of low blood sugar, and oral steroids can raise blood sugars, but a mild steroid cream doesn’t do that.

There were 32 “use cautiously”, many of them quite tangential, like the blessed fungus cream and Barton’s history of hepatitis C.

On the last two pages were the dietary warnings, including not to swallow your atorvastatin with grapefruit juice, or to mix your pain pills with alcohol.

I hate to sound uppity, but no amount of pop-up interaction alerts or other forms of “decision support” can replace basic medical education. In Barton’s case, the only warning I needed was the one about his dofetilide, which he gets from his cardiologist, and the antibiotic I wanted to prescribe. The aspirin-Pradaxa interaction is common sense, and the baby aspirin-Symbicort interaction is nonsense. And if I were to even read through the eight pages worth of precautions and “use with caution”, I would have doubled the 15 minutes it took to assess and document his infection in the first place. Or I could have listened to a tutorial about evaluating lung sounds – how much coaching do the EMR designers think we need?

So, here is my suggestion: Make these warnings behave like some computerized card games – let users decide based on their skill level whether to get all the warnings or only the critical ones that are not generic class effects we all learned in pharmacology class. Because when everything is a red alert, alarm fatigue sets in and all the warnings are wasted.

It reminds me of the story about the boy who cried wolf…

Three Challenges in the Art of Prescribing Warfarin

The blood thinner we have used for so many years is gradually being replaced by the novel anticoagulants, which don’t require laboratory monitoring and have fewer interactions. But for some indications, warfarin is still preferred and for many patients, it is still by far the more affordable anticoagulant.

Dosing warfarin has always been an art and it seems to be less often mastered than it used to be. The three challenges are drug interactions, food interactions and dosing schedules.

DRUG INTERACTIONS

Just the other day, I was covering for a colleague and got an urgent message that her patient had a supratherapeutic INR – too much thinning of his blood. I asked the medical assistant to find out if the patient was taking any new medications, like ciprofloxacin, that might interact with the warfarin. I just threw that drug name out because it is such a common and overlooked interaction. Sure enough, somebody else had prescribed ciprofloxacin two days earlier for a urinary infection.

I played detective and tracked down the urine culture, which showed the coli bacteria were resistant to ciprofloxacin, but sensitive to nitrofurantoin (safe) and Bactrim (unsafe). I messaged the prescribing provider, who changed the patient’s antibiotic to nitrofurantoin, so I just ordered the warfarin held for two days.

Many providers seem to be unaware or less paranoid than I am about drugs that interact with warfarin. I once had a patient end up in the intensive care unit with critical internal bleeding because I prescribed levofloxacin with plans to check her INR every couple of days during her antibiotic course. That was clearly not cautious enough in her case.

I have seen great variability in how much other drugs affect the effect of warfarin, especially azithromycin, amoxicillin-clavulanate and also acetaminophen and prednisone, both of which in most people doesn’t seem to cause much trouble. But I worry about all of them, plus sulfamethoxazole, metronidazole, fluconazole, NSAIDs (obviously) and new starts of amiodarone, sertraline, carbamazepine and many others. Over the counter agents to worry about include fish oil, ginkgo biloba and St Johns Wort.

This is not a complete listing, and since most of us have EMRs that warn us of interactions you would think close calls like this would never happen. The problem here is the multitude of basic warnings providers know in their sleep, so that the less famous issues drown among the unnecessary alerts (see my posts about Alarm Fatigue).

I end up using epocrates’ interaction checker on my iPhone to double check sometimes, but, as I said, I’ve been burned so I know this stuff know.

FOOD INTERACTIONS

Warfarin interferes with the role of vitamin K in the coagulation process. Therefore, if you flood your system with foods rich in vitamin K, which is the pharmacological antidote to warfarin, you decrease the effectiveness of warfarin. A week before my ciprofloxacin case, one of my own patients suddenly had a low INR. “Ask him if he’s been eating fiddleheads”, I told Autumn. Sure enough, this Maine spring delicacy was the culprit. The season is short and he wasn’t going to have more, he said, so I didn’t change his dose schedule.

A lot of people are under the impression they cannot eat green vegetables while on warfarin. I tell them that’s like saying you can’t open your windows in the winter if you heat with wood. Imagine you know how many logs to put in the wood stove at certain outdoor temperatures. Then imagine you decide to open a window now and then. You would then have to adjust your fire whenever you opened the window, compensating for the heat loss. If you instead decided to leave a crack open all the time, you would quickly figure out your new firewood budget.

So I simply tell my patients, “eat all the greens you want, but be sure to keep the amount the same every day”.

DOSING WARFARIN: DON’T DRIVE LIKE YOU’RE MR. MAGOO AND PLEASE LEARN FROM YOUR MISTAKES

Mr. Magoo is like me without my glasses. If I were to drive in a snowstorm without my glasses, I would only see a couple of feet in front of me and I would be turning my steering wheel a lot more than necessary. I wouldn’t be able to tell if I was entering a small or a big curve, for instance. If I could see further ahead, I would make smaller corrections. Many providers will look at the current INR value and the previous one, and the current warfarin dose. Then they change the dose. Unless you have a flowsheet that tells you that the last time you made that change, bad things happened, you will make the same poor choice again. On paper, such flowsheets are easy to maintain, but – believe it or not – in many EMRs it is just too darn cumbersome to do.

I have a three ring binder with all my warfarin patients’ flowsheets. It helps me avoid Mr. Magoo type errors and it also serves as a low tech way of making sure no warfarin patients fall off my radar screen. Autumn or I sometimes just flip through the binder to make sure our flock doesn’t wander off, so to speak.

An old fashioned method of managing an old fashioned medication…

Voicemail, Repeat Requests and Multitasking: Inefficiencies in Today’s Healthcare

My nurse regularly gets at least 50 voicemails every day, many saying “please call me back”.

I have one patient who frequently tests the patience of our clinic staff by calling multiple times for the same thing. He is the most dramatic example of what seems to be a widely held belief that physicians, nurses and medical assistants sit at their desks and answer phone calls all or most of their time. But when we do, we are often hampered by busy signals, phone tag or “voice mail not set up”. Electronic messaging isn’t a panacea, because patients don’t necessarily know what we need to know in order to answer their questions correctly and efficiently at first contact.

Pharmacies, too, create duplicate requests that bog down our workdays. In my EMR, if an electronic refill request doesn’t get a response the day it comes in, the “system” sends a repeat request every day until it gets done. This is one reason I look like I am further behind on “tasks” than I really am. To top it off, every single refill request generated by the “system” comes with a red exclamation point next to it. This happens even when a patient has just picked up their last 90 day refill – a case where I theoretically should have 89 days to respond. Meanwhile, my system has no way of flagging truly urgent refill requests. This “alarm fatigue” is common in EMRs today.

The business model in today’s healthcare is that reimbursable activities (seeing patients in person or via telemedicine) are scheduled back to back, all day long. There is a universal assumption that this will still provide enough slack to deal with prescription refills, phone calls, incoming reports and the further ordering and feedback to patients prompted by them. And did I mention EMR documentation? Multitasking, or rather, constantly switching between different kinds of tasks, is not a sane or efficient way to work.

Providers, as salaried employees, are universally expected to get their work done on their own time (jokingly called “pajama time”). This creates varying degrees of stress and burnout. But nurses and medical assistants have a different stress. As hourly employees, they are theoretically entitled to overtime pay if they can’t finish their work during their normal working hours. But that is expensive for healthcare organizations and often discouraged or forbidden.

In Sweden, known for its somewhat stodgy bureaucracy, clinics almost universally have “telefontid”, a portion of the day when patients can call, or when staff are not seeing patients but returning calls – the details can vary. This may not be ideal customer service, but it at least acknowledges that multitasking in healthcare isn’t always necessary and certainly not healthy.

A growing trend in this country, mysterious to me and a generator of patient frustration and employee stress, is that in spite of all our expensive computers and phone systems – or perhaps because of them – most clinics, even large organizations, can’t afford to have someone answer the telephone.

St Joseph Hospital in Bangor usually answers on the first ring, and the main operator (I know her voice well) is efficient and helpful. My mother worked as an operator for a big hotel and also at one point the phone company. I remember watching her efficiency plugging in those little cables to transfer callers to the right department. Most clinics and hospitals tell you to hang up and call 911 if you’re in trouble and make you “listen carefully” to all the options, threatening that they “may have changed” and eventually you end up in somebody’s voicemail.

When everybody is talking about patient centeredness, customer experience and such things, why isn’t it obvious that incoming calls and other types of requests need to be prioritized as they arrive and not just dumped, unsorted, in someone’s voicemail or inbox?

Organizations appear to be paranoid about being held responsible if non-clinicians are put in a position to “triage” incoming calls. But it isn’t rocket science – everybody does it at home, with their kids, pets and themselves. I believe it may be an even greater liability to have an automated telephone system people get lost or stuck in.

Here are two slides from a staff education talk I gave 10 years ago about common sense telephone triage.

The telephone used to be a powerful tool, connecting people with businesses, services and each other. It no longer works like it used to, because nobody’s answering.

We Use Too Many Medications: Be Very Afraid of Interactions

I happened to read about the pharmacodynamics of parenteral versus oral furosemide when I came across a unique interaction between this commonest of diuretics and risperidone: Elderly dementia patients on risperidone have twice their expected mortality if also given furosemide. I knew that all atypical antipsychotics can double mortality in elderly dementia patients, but was unaware of the additional risperidone-furosemide risk. Epocrates only has a nonspecific warning to monitor blood pressure when prescribing both drugs.

This is only today’s example of an interaction I didn’t have at my fingertips. I very often check Epocrates on my iPhone for interactions before prescribing, because – quite frankly – my EMR always gives me an entire screen of fine print idiotic kindergarten warnings nobody ever has time to read in a real clinical situation. (In my case provided by the otherwise decent makers of UpToDate.)

I keep coming back in my thoughts to, and blogging about, drug interactions. And every time I run into one that surprised me or caused harm, I think of the inherent, exponential risks of polypharmacy and the virtues of oligopharmacy.

One conclusion I have come to is that too often the benefit of our prescribed medication is actually too small to justify the drug. The way drugs are approved today is pretty much that they have to bring a 20% or so advantage over placebo for a certain outcome. Other than the drug versus placebo, all other factors are ignored or “controlled for”, which is easier said than done.

But this whole premise seems wrong to me: If pill A is 20% better than placebo at lowering blood pressure, but salt restriction, weight loss, exercise and stress reduction are twice as powerful as pill A, why are we so stuck on prescribing pill A? If a Mediterranean diet lowers cardiovascular risk as much as atorvastatin, why isn’t that a blockbuster/no-brainer intervention?

The health of our nation is not great, in spite of all the pills at our disposal. And the more pills we prescribe, the more we risk interactions: antidepressants and cholesterol pills with blood thinners, gout medicines with cholesterol pills, mood stabilizers with cardiac medications and on and on and on.

May we all take a step back and look at the big picture of what we are doing and where we are heading.

Donald W Light from the Harvard Center of Ethics wrote in 2014:

Few people know that new prescription drugs have a 1 in 5 chance of causing serious reactions after they have been approved. That is why expert physicians recommend not taking new drugs for at least five years unless patients have first tried better-established options, and have the need to do so.

Few know that systematic reviews of hospital charts found that even properly prescribed drugs (aside from misprescribing, overdosing, or self-prescribing) cause about 1.9 million hospitalizations a year. Another 840,000 hospitalized patients are given drugs that cause serious adverse reactions for a total of 2.74 million serious adverse drug reactions. About 128,000 people die from drugs prescribed to them. This makes prescription drugs a major health risk, ranking 4th with stroke as a leading cause of death. The European Commission estimates that adverse reactions from prescription drugs cause 200,000 deaths; so together, about 328,000 patients in the U.S. and Europe die from prescription drugs each year. The FDA does not acknowledge these facts and instead gathers a small fraction of the cases.

There are obviously more recent statistics out there, but this piece struck me because it was published in a forum about ethics. Think about that for a moment: We are subjecting our patients to known and unknown risks of harm with every prescription we issue.

The Art of Being Sick

Almost daily, I get messages like this one: “What can I take for a cold?”

My answer is usually in the negative. The more time I have or the needier the request seems, the more I might elaborate, but the bottom line is that I don’t recommend anything for “fighting a cold”. In fact, I recommend surrendering to it.

Why take an antipyretic like acetaminophen/paracetamol, when such drugs have been proven to prolong viral illnesses? Why take antihistamines or decongestants when they thicken mucus and increase the risk of developing a sinus infection? Why take a cough suppressant if there is sputum to be eliminated? Why hide the symptoms of a contagious illness only so you can go to work and infect others?

My weekend of preliminary symptoms came into full bloom when the alarm went off at ten past five this morning. Coffee with sugar and half-and-half never felt so good going down my throat, even though I could barely taste anything. I coughed so hard that the cat, who usually sharpens her claws on my chest in the morning, decided to keep her distance.

A text message to my office manager and out to the barn with warm water and grain for the horse and the goats, then I was back in bed.

I read The New York Times on my iPad and paused after reading the article about the blood pressure medication Benicar (olmesartan) causing a celiac-like diarrhea. Isn’t that what Mr. Waddell is on, the man who stopped his stomach pill, omeprazole, to no avail? And I had been trying to tell him to give up beer, since that was the only thing I could blame his symptoms on. I resisted the temptation to log into our electronic medical record system to check his medication list; I can do that when I get back to the office in a day or two.

I dozed for an hour or so, then I made amends with the cat. I managed to sign the grandchildren’s Valentine’s Day cards before it was time to let the barn animals out in the pale February sunshine.

I reflected on the last time I was sick. That time I had a mysterious and rather unnerving illness that made me a little concerned I might have something serious. Only my profound fatigue and suppressed brain activity kept me from actually worrying about it. This time, everything is utterly familiar, and I have simply settled in for a few days of submission; my life has to slow down, and there is really nothing I can do about it.

The day inches on. I sleep, read and cough. I hear my wife fixing supper downstairs. She is playing Mozart. But why “Requiem”?

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.

BOOKS BY HANS DUVEFELT, MD

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