Development of an emergency medicine pharmacy intensity score tool.

PURPOSE: Emergency medicine pharmacists (EMPs) have been demonstrated to have a positive impact on patient outcomes in a variety of clinical scenarios in the emergency department (ED), yet their distribution across the nation is suboptimal. An emergency medicine pharmacy intensity score tool (EMPIST) would not only facilitate the quantification of EMP staffing needs and ideal resource deployment times, but would also allow practitioners to triage patient care activities. The purpose of this investigation was to develop an EMPIST and evaluate its relationship to EMP activities. METHODS: This was a multicenter, prospective, observational analysis of an EMPIST developed by practicing EMPs. EMPs prospectively documented their clinical activities during usual care for patients in their ED. Spearman's rank-order correlation was used to determine any correlation between the EMPIST and pharmacist activities. RESULTS: In total, 970 EMP activities and 584 EMPIST items were documented in 352 patients by 7 EMPs across 7 different EDs. The most commonly documented EMP interventions performed were bedside monitoring (12.7%), initiation of nonantimicrobial therapy (12.6%), and antimicrobial therapy initiation and streamlining (10.6%). The total EMPIST was found to significantly correlate with EMP activities, and this correlation was consistent across both "diagnostic/presentation" and "medication" items (P < 0.001 for all comparisons). CONCLUSION: The EMPIST significantly correlated with EMP activities, with consistent correlation across all subgroups. Its utilization has the potential to enhance bedside clinical practice and optimize the deployment of limited EMP services. Additional investigations are needed to examine the validity of this tool and identify any relationship it may have to patient outcomes.

Continuous infusion versus intermittent infusion vancomycin in a burn center intensive care unit.

BACKGROUND: Vancomycin is a common and critical drug for empiric antimicrobial therapy in the infected burn patient. However, profound physiologic changes may impede the clinical effectiveness and amplify the potential nephrotoxicity of vancomycin. METHODS: This was a retrospective cohort study at a large academic medical center and regional burn center. Patients with ≥10% total body surface area burn that received intravenous vancomycin were considered for study inclusion. Patients were assigned to the intermittent infusion or continuous infusion cohort if they received vancomycin for ≥48 h with ≥1 documented vancomycin serum concentration. The target steady state drug level for continuous infusion was 17-22 mg/L. The target steady state trough drug level for intermittent infusion was 15-20 mg/L. The primary efficacy and safety outcomes were time to therapeutic drug level and nephrotoxicity respectively. RESULTS: Thirty continuous infusion subjects with 88 plasma drug levels and thirty intermittent infusion subjects with 80 plasma drug levels were analyzed within the study period. There was a significant difference in the number of subjects that achieved a plasma vancomycin level within the target range during the course of therapy (73.3% for continuous infusion vs. 26.7% for intermittent infusion, p = 0.0003). The time to therapeutic level was 3.90 days for continuous infusion and 5.22 days for intermittent infusion (p = 0.0393). Nephrotoxicity occurred less frequently in the continuous infusion cohort (23.3% vs. 53.8%). CONCLUSION: Continuous infusion vancomycin was associated with more rapid attainment of target levels and a lower rate of nephrotoxicity.