Factors Associated With Physical Restraint in an Urban Emergency Department.

STUDY OBJECTIVE: To determine what patient characteristics were associated with the application of physical restraints in our emergency department (ED). METHODS: This was a retrospective analysis of encounters in the ED of an urban, Level I academic trauma center. We included ED encounters of adult patients (aged ≥18 years) during a 5-year period starting in 2017. We evaluated the independent association of restraint application during an encounter using a generalized estimating equation model. RESULTS: There were 464,031 ED encounters during the time period from 162,244 unique patients, including 34,798 (7.5%) with restraint application, comprising 18,166 unique patients. Several variables were associated with an increased likelihood of restraint use during an encounter. The variable with the highest odds ratio was intoxication with drugs or alcohol (adjusted odds ratio [aOR] 8.29; 95% confidence interval (CI) 7.94 to 8.65). American Indian race was associated with increased odds of restraint application (aOR 1.42; 95% CI 1.31 to 1.54) compared to the reference value of White race. Black race (aOR 0.58; 95% CI 0.55 to 0.61) and Hispanic ethnicity (aOR 0.42; 95% CI 0.37 to 0.48) were associated with lower odds of restraint application. CONCLUSIONS: Drug and alcohol intoxication were most closely associated with restraint. Encounters in which the patient was American Indian had higher odds of restraint, but this study does not replicate prior findings regarding other racial disparities in restraint.

Comparing Intubation Rates in Patients Receiving Parenteral Olanzapine With and Without a Parenteral Benzodiazepine in the Emergency Department.

STUDY OBJECTIVE: United States prescribing information recommends against coadministration of injectable olanzapine with injectable benzodiazepines due to a risk of cardiorespiratory depression, whereas European prescribing information recommends the 2 drugs not be administered within 60 minutes of each other. In contrast, a recently published American College of Emergency Physicians clinical policy recommends injectable olanzapine and benzodiazepines be coadministered for treating severe agitation. We sought to compare injectable olanzapine with and without injectable benzodiazepines for evidence of cardiorespiratory depression. METHODS: We performed a retrospective study of patients in an urban emergency department from January 2017 through November 2019 who received parenteral olanzapine with or without parenteral benzodiazepines. We included patients receiving 2 total medication doses, either olanzapine+benzodiazepine or 2 doses of olanzapine, coadministered within 60 minutes. The primary outcome was tracheal intubation in the emergency department. Secondary outcomes included hypotension (systolic blood pressure less than 90 mmHg) and hypoxemia (SpO2 less than 90%). RESULTS: We identified 693 patients (median [alcohol]=210 mg/dL, median age=37 years [IQR 29 to 49]). In total, 549 received 2 doses of olanzapine, and 144 patients received olanzapine and a benzodiazepine. We found no difference in intubation rates between the olanzapine-only group (21/549, 3.8%) and the olanzapine+benzodiazepine group (5/144, 3.5%; difference=0.3%, 95% confidence interval -3.0% to 3.7%). Rates of hypoxemia (2% olanzapine-only and 3% olanzapine+benzodiazepine) and hypotension (9% both groups) also were not different between groups. CONCLUSION: We found no difference in cardiorespiratory depression between patients receiving only olanzapine versus olanzapine plus a benzodiazepine.

Feasibility and Safety of Oral Risperidone to Treat Prehospital Agitation.

OBJECTIVE: Agitation is a common prehospital problem and frequently presents without a clear etiology. Given the dynamic environment of the prehospital setting, there has historically been a varied approach to treating agitation with a heavy reliance on parenteral medications. Newer best practice guidelines recommend the incorporation of oral medications to treat patients experiencing agitation. Therefore, we evaluated the use of oral risperidone in a single system after a change in protocol occurred. METHODS: This was conducted as a retrospective chart review of an urban/suburban Emergency Medical Services system over the period of 8 months. The first day this medication was implemented throughout the service was included. Charts were included for selection if they included risperidone oral dissolving tablet (ODT) as a charted medication. The primary outcome was administration of additional medications to treat agitation. Exploratory outcome measures included acceptance of medication, documented injury to paramedics, documented injuries to patients, scene times, and adverse events that could possibly be linked to the medication. RESULTS: A total of 552 records were screened for inclusion. Risperidone was offered to 530 patients and accepted by 512 (96.6%). Of these 512 patients, the median age of included patients was 39 years old (IQR 29-52 years old) with a range of 18-89 years old. Rescue or additional medications for agitation were required in 9 (1.8%) cases. There were a total of 4 (0.8%) potential complications following administration of risperidone. There were no reported assaults with subsequent injuries to prehospital personnel or injuries sustained by patients reported in this study. CONCLUSIONS: Risperidone ODT was found to be a safe and effective medication to treat mild agitation in a large urban and suburban EMS system. The need for additional medications to treat agitation was rare, and there were no documented injuries to either patients or paramedics.

Massive Sodium Nitrite Overdose: A Case for Prehospital Methylene Blue.

Sodium nitrite overdose leads to profound methemoglobinemia and may quickly progress to death. It is an increasingly common method of suicide and is often fatal. Methylene blue is an effective but time-sensitive antidote that has the potential to save lives when administered early. In this case report, we describe a fatal sodium nitrite overdose and the subsequent creation of a prehospital protocol for our large urban Emergency Medical Services system.

QT prolongation, torsades des pointes, and cardiac arrest after 4 mg of IV ondansetron.

Ondansetron is a commonly used antiemetic in the emergency department despite a 2011 FDA warning regarding dose-related QTc prolongation and torsades des pointes (TdP). Cases of TdP from small ondansetron doses administered in the emergency department are lacking. A 41-year-old-woman with alcohol use disorder on no medications or supplements presented to an emergency department with one day of nausea, vomiting, and epigastric pain. Examination revealed a pulse of 77 beats/min and epigastric tenderness. The patient received 4 mg IV ondansetron, 30 mg IV ketorolac, and was placed on cardiac monitoring. ECG obtained one minute after ondansetron demonstrated premature ventricular contractions with QTc = 653 ms. Thirteen minutes after receiving ondansetron she suffered TdP and cardiac arrest. She received immediate CPR and IV epinephrine with successful defibrillation at one minute. She then received IV magnesium. Post-arrest ECGs demonstrated persistent QTc prolongation immediately and at three hours post-arrest. Laboratory studies, drawn prior to arrest, demonstrated hypokalemia (3.2 mEq/L), hypomagnesemia (1.3 mg/dL), and elevated lipase (4918 IU/L). She received no additional QT-prolonging agents. Transthoracic echocardiogram and troponins were normal; ECG intervals completely normalized within 12 h and she was discharged neurologically intact. The patient returned 18 months later with recurrent pancreatitis and similar electrolyte abnormalities; QT-prolonging drugs were avoided at that time and her course was uncomplicated. QT prolongation with subsequent torsades des pointes and cardiac arrest may occur in high-risk patients receiving small doses of ondansetron. Further studies are warranted to determine the safest antiemetic for use in the emergency department.

Comparison of efficacy and frequency of akathisia and dystonia between olanzapine, metoclopramide and prochlorperazine in ED headache patients.

STUDY OBJECTIVE: To compare the efficacy and frequency of akathisia and dystonia between the dopamine antagonist headache medications olanzapine, metoclopramide and prochlorperazine. METHODS: This was a retrospective observational cohort study of patients presenting to a large urban level one trauma center between 2010 and 2018. Inclusion criteria was age ≥ 18 who presented to the emergency department with a chief complaint of headache who received either olanzapine, metoclopramide or prochlorperazine. The primary outcome was need for rescue medication. Secondary outcomes were receiving medication for either akathisia or dystonia. Logistic regression was used to identify differences between the three cohorts up to 72 h from initial presentation. RESULTS: There were 5643 patients who met inclusion criteria. Olanzapine was the most commonly used drug (n = 2994, 53%) followed by prochlorperazine (n = 2100, 37%) and metoclopramide (n = 549, 10%). After adjusting for age and gender, there were no differences in risk for receiving rescue therapy or developing akathisia or dystonia. CONCLUSION: During initial ED visit and up to 72 h after receiving olanzapine, metoclopramide or prochlorperazine, we found no difference in risk for requiring rescue medication or developing akathisia or dystonia.

A Prospective Study of Intramuscular Droperidol or Olanzapine for Acute Agitation in the Emergency Department: A Natural Experiment Owing to Drug Shortages.

STUDY OBJECTIVE: Intramuscular medications are commonly used to treat agitation in the emergency department (ED). The purpose of this study is to compare intramuscular droperidol and olanzapine for treating agitation. METHODS: This was a prospective observational study of ED patients receiving intramuscular droperidol or olanzapine for acute agitation. The treating physician determined the medication and dose; however, over time drug shortages made either olanzapine (July to September 2019) or droperidol (November 2019 to March 2020) unavailable, creating a natural experiment. The primary outcome was time to adequate sedation, assessed by the Altered Mental Status Scale (AMSS), defined as time to AMSS score less than or equal to 0. RESULTS: We analyzed 1,257 patients (median age 42 years; 73% men); 538 received droperidol (median dose 5 mg) and 719 received olanzapine (median dose 10 mg). The majority of patients (1,086; 86%) had agitation owing to alcohol intoxication. Time to adequate sedation was 16 minutes (interquartile range 10 to 30 minutes) for droperidol and 17.5 minutes (interquartile range 10 to 30 minutes) for olanzapine (absolute difference -0.7 minutes; 95% confidence interval -2.1 to 0.5 minutes). Adjusted Cox proportional hazard model analysis revealed no difference between groups in time to sedation (hazard ratio for adequate sedation for droperidol compared with olanzapine 1.12; 95% confidence interval 1.00 to 1.25). Patients receiving olanzapine were more likely to receive additional medications for sedation (droperidol 17%; olanzapine 24%; absolute difference -8% [95% confidence interval -12% to -3%]). We observed no difference between drugs regarding adverse effects except for extrapyramidal adverse effects, which were more common with droperidol (n=6; 1%) than olanzapine (n=1; 0.1%). CONCLUSION: We found no difference in time to adequate sedation between intramuscular droperidol and olanzapine.

Medical needs of emergency department patients presenting with acute alcohol and drug intoxication.

STUDY OBJECTIVE: Some contend that patients with acute alcohol or illicit substance intoxication should be treated in outpatient detoxification centers rather than in the ED. However, these patients often have underlying acute medical needs. We sought to determine the frequency of medical interventions required by ED patients with alcohol or illicit substance intoxication. METHODS: This was a prospective observational study of consecutive ED patients presenting to an urban tertiary care ED with altered mental status due to alcohol or illicit substance use. We performed data collection for patients deemed to be low-risk for complications, as defined by receiving care in an intoxication observation unit. Trained staff observed and recorded all medical interventions, including medications administered, diagnostic testing, procedures performed, and airway interventions. The incidence of agitation was recorded using the Altered Mental Status Scale (AMSS, ordinal scale from -4 to +4, where +4 is most agitated). The data analysis is descriptive. RESULTS: This analysis included 2685 encounters (1645 unique patients; median age 39; 73% male) from January to May 2019. Average breath alcohol concentration was 0.20 g/dL (range 0.00-0.47). There were 89% encounters with alcohol intoxication, and in 17% encounters the patient was suspected or known to have drug intoxication (either alone or in conjunction with alcohol use). On arrival to the ED, 372 (14%) had agitation (AMSS +1 or higher) and 32 (1%) were profoundly agitated (AMSS +4). In total, 1526 (56%) received at least one intervention that could not be provided by a local detoxification or sobering facility. Of the study population, 955 (36%) received a sedating medication, 903 (34%) required physical restraints for patients or staff safety, 575 (21%) underwent imaging studies, 318 (12%) underwent laboratory testing, 367 (13%) received another intervention (IV access, EKG, splinting, wound care, etc). Additionally, 111 (4%) patients received an airway intervention (19 intubation, 23 nasal airway, 85 supplemental oxygen) and 275 (10%) required repositioning to protect the airway. There were 168 (6%) patients admitted to the hospital. CONCLUSION: In this population of relatively low-risk ED patients with drug and alcohol intoxication, a substantial proportion of patients received medical interventions.

Extracorporeal Membrane Oxygenation for Poisonings Reported to U.S. Poison Centers from 2000 to 2018: An Analysis of the National Poison Data System.

OBJECTIVES: To assess trends in the use of extracorporeal membrane oxygenation for poisoning in the United States. DESIGN: Retrospective cohort study. SETTING: The National Poison Data System, the databased owned and managed by the American Association of Poison Control Centers, the organization that supports and accredits all 55 U.S. Poison Centers, 2000-2018. PATIENTS: All patients reported to National Poison Data System treated with extracorporeal membrane oxygenation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 407 patients met final inclusion criteria (332 adults, 75 children). Median age was 27 years (interquartile range, 15-39 yr); 52.5% were male. Median number of ingested substances was three (interquartile range, 2-4); 51.5% were single-substance exposures. Extracorporeal membrane oxygenation use in poisoned patients in the United States has significantly increased over time (z = 3.18; p = 0.001) in both adults (age > 12 yr) and children (age ≤ 12 yr), increasing by 9-100% per year since 2008. Increase in use occurred more commonly in adults. We found substantial geographical variation in extracorporeal membrane oxygenation use by geospatially mapping the ZIP code associated with the initial call, with large, primarily rural areas of the United States reporting no cases. Overall survival was 70% and did not vary significantly over the study period for children or adults. Patients with metabolic and hematologic poisonings were less likely to survive following extracorporeal membrane oxygenation than those with other poisonings (49% vs 72%; p = 0.004). CONCLUSIONS: The use of extracorporeal membrane oxygenation to support critically ill, poisoned patients in the United States is increasing, driven primarily by increased use in patients greater than 12 years old. We observed no trends in survival over time. Mortality was higher when extracorporeal membrane oxygenation was used for metabolic or hematologic poisonings. Large, predominantly rural regions of the United States reported no cases of extracorporeal membrane oxygenation for poisoning. Further research should focus on refining criteria for the use of extracorporeal membrane oxygenation in poisoning.

Utility of plain abdominal radiography in adult ED patients with suspected constipation.

BACKGROUND: Abdominal radiographs are often obtained in ED patients with suspected constipation, although their utility in adults is not well understood. We sought to compare ED management when an abdominal radiograph is and is not obtained. METHODS: We performed a retrospective chart review study of adult ED patients with a chief complaint of constipation from 2010 through 2016. Trained abstractors recorded radiologic tests ordered, treatments received, and final diagnosis. We determined the physician interpretation of the abdominal radiograph and its use in clinical decision making. RESULTS: Of 1142 eligible patients, 481 (42%) patients underwent abdominal radiography. Stool burden rated moderate or large was observed in 271 patients (46%). Sixteen patients (3%) were diagnosed with small bowel obstruction; 15/16 of these patients had high risk features such as old age, complex surgical history, history of small bowel obstruction, abdominal malignancy, or presented with vomiting or inability to pass flatus. Of the 197 patients with no or mild stool burden or normal radiograph, 109 (55%) were diagnosed with constipation and 89 (45%) received constipation treatment in the ED. Conversely, of the 271 patients with moderate or greater stool burden, 114 (42%) received no treatment for constipation in the ED and 104 (38%) were prescribed no discharge medications for constipation; 77 of these 271 patients (28%) were diagnosed with something other than constipation. CONCLUSION: Plain abdominal radiography did not appear to significantly affect the ED management of patients presenting with constipation; it was common for patients to receive treatment that was in direct opposition to radiographic findings. Though a small number of patients had concerning diagnoses identified on plain radiography, the history and physical examination should have sufficiently excluded simple constipation, prompting an alternate diagnostic approach. Fecal loading on radiography does not preclude a more serious diagnosis. In conclusion, abdominal radiography appears to have low value in patients with constipation.

Fatal Yellow Oleander Poisoning Masquerading as Benign Candlenut Ingestion Taken for Weight Loss.

BACKGROUND: Candlenuts (Aleurites moluccana) and yellow oleander seeds (Thevetia peruviana) bear a physical resemblance to one another. Candlenuts are benign and marketed as weight loss supplements. Yellow oleander seeds, however, contain toxic cardioactive steroids; as few as 2 seeds may cause fatal poisoning. Because of their physical similarities, the potential for a lethal substitution exists. CASE REPORT: A 63-year-old woman presented to the emergency department with vomiting after ingesting 5 of what she believed to be candlenuts that were ordered online under the colloquial name "Nuez de la India" for the purpose of weight loss. She was bradycardic (nadir pulse of 30 beats/min) and hyperkalemic (serum potassium 7.3 mEq/L). Within hours of presentation she suffered a ventricular fibrillation arrest, followed by a terminal asystolic arrest. Postmortem analyses of liver tissue and the seeds were consistent with fatal T. peruviana poisoning. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: T. peruviana seeds contain toxic cardioactive steroids; their physical resemblance to candlenuts poses a risk of potentially fatal substitution. Therapy with high-dose digoxin specific immune fragments (20-30 vials) may be helpful.

The Use, Safety, and Efficacy of Olanzapine in a Level I Pediatric Trauma Center Emergency Department Over a 10-Year Period.

OBJECTIVES: Olanzapine is a second-generation antipsychotic increasingly used in emergency medicine for many indications. Literature on its use in children is sparse. Our objectives were to describe the use, safety, and efficacy of olanzapine in pediatric emergency patients. METHODS: A structured chart review was performed of patients 18 years old or younger receiving olanzapine from 2007 to 2016 in the emergency department of a pediatric level I trauma center. RESULTS: A total of 285 children received olanzapine. Mean age was 16.4 years (range, 9-18 years); 121 were male (42.8%). Primary indications for olanzapine included agitation (n = 166, 58.3%), headache (n = 58, 20.4%), nausea/vomiting/abdominal pain (n = 37, 12.5%), unspecified pain (n = 20, 7%), and other (n = 4, 1.4%). Route of olanzapine administration was intramuscular (n = 160, 56%; median dose, 10 mg; range, 2.5-20), intravenous (n = 101, 36%; median dose, 5 mg; range, 1.25-5), and oral (n = 24, 8%; median dose, 10 mg; range, 5-10). For agitated patients, 28 (17%) received another sedative within 1 hour. For headache patients, 5 (8.6%) received another analgesic. For gastrointestinal complaints, 5 patients (13.5%) received another analgesic/antiemetic. Adverse respiratory events were hypoxia (pulse oximetry reading, in percentage, <92%; n = 7, 2.4%), supplemental oxygen placement (n = 9, 3.2%), and intubation (n = 2, 0.7%). No patient died or had a dysrhythmia. One patient experienced dystonia. CONCLUSIONS: Olanzapine seems safe when used for a variety of conditions in pediatric emergency patients. It may be effective for acute agitation, primary headache, and gastrointestinal complaints.

Urine Drug Screens in the Emergency Department: The Best Test May Be No Test at All.

The manuscript purpose is to provide a resource for clinicians on the functionality and pitfalls of the rapid urine drug screen for clinical decision making. Many providers remain under-informed about the inherent inaccuracies. The rapid urine drug screen is the first, and often only, step of drug testing. In the majority of emergency departments the urine drug screen is a collection of immunoassays reliant on an interaction between the structure of a particular drug or metabolite and an antibody. Drugs in separate pharmacologic classes often have enough structural similarity to cause false positives. Conversely, drugs within the same pharmacologic class often have different enough structures that they may result in inappropriate negatives. This lack of sensitivity and specificity significantly reduces the test utility, and may cause decision-making confusion. The timing of the drug screen relative to the drug exposure also limits accuracy, as does detection threshold. Confirmatory steps following the initial immunoassay include chromatography and/or mass spectrometry. These are unavailable at many institutions and results rarely return while the patient is in the emergency department. In addition, institutional capabilities vary, even with confirmatory testing. Confirmation accuracy depends on a number of factors, including the extent of the catalog of drugs/metabolites that the facility is calibrated to detect and report. In summary, the standard emergency department urine drug screen is a test with extremely limited clinical utility with multiple properties contributing to poor sensitivity, specificity, and accuracy. The test should be used rarely, if ever, for clinical decision making.

Phenibut exposures and clinical effects reported to a regional poison center.

BACKGROUND: Phenibut is a synthetically produced central nervous system (CNS) depressant that is structurally similar to the inhibitory neurotransmitter γ-aminobutyric acid (GABA). Phenibut has been identified as a drug of abuse with numerous clinical effects in overdose and a withdrawal syndrome with chronic use. The purpose of this study is to report the incidence of exposure calls regarding phenibut to a poison center, describe the reasons for its use and clinical effects. METHODS: Study subjects were identified using Toxicall®, the electronic medical record utilized by the Minnesota Poison Control System. All phenibut exposure calls from January 2000 through December 2018 were included. Analysis was performed on incidence of exposure calls, reported reasons for use, signs and symptoms, coingestants, and outcome. RESULTS: There were 56 exposure calls over 19 years with 48 (85.7%) calls within the past five years. Over 50% of patients had CNS effects and 10.7% had withdrawal concerns. Twenty-seven patients (48%) had abuse as the reason for use and 13 (23%) used phenibut to treat anxiety. There were documented coingestants in 35.7% of patients. No patients died due to reported phenibut use, though 11 patients (19.6%) were intubated. CONCLUSION: Exposure calls to a regional poison center regarding phenibut have increased over the past five years. CNS depression was common, and associated with significant clinical outcomes including respiratory failure requiring intubation. As phenibut is easily attainable and exposures appear to be increasing, physicians should be aware of phenibut-associated CNS and respiratory depression and be prepared to manage airways appropriately.

Comparison of two glycemic discharge goals in ED patients with hyperglycemia, a randomized trial.

STUDY OBJECTIVE: Hyperglycemia is commonly encountered in the ED; the importance of glucose reduction in patients well enough to be discharged is unknown. METHODS: We conducted a prospective, randomized trial of ED patients with hyperglycemia with a glucose value 400-600 mg/dL who were discharged from the ED, excluding those with type 1 diabetes mellitus. Patients were randomly assigned to a discharge glucose goal, <350 mg/dL (moderate control) or < 600 mg/dL (loose control). The primary outcome was ED length of stay. RESULTS: Among 110 enrolled patients, 57 were assigned to moderate and 53 to loose glycemic control. Median (IQR) length of stay was 211 min (177-288 min) for the moderate group and 216 min (151-269 min) for the loose group (difference, 17 min [95% CI -15 to 49 min]). ED length of stay for those with an actual discharge glucose <350 mg/dL was 29 min longer (95% CI -1 to 59 min). Repeat ED visits for hyperglycemia (7% vs 6%), hospitalization for hyperglycemia (0% vs 2%), and hospitalization for any reason (4% vs 8%) did not differ significantly between groups. CONCLUSION: In the intention-to-treat analysis, ED length of stay and 7-day outcomes were not significantly different whether moderate or loose glycemic control was pursued. However, the length of stay for those with discharge glucose <350 mg/dL was approximately 29 min longer. ED glycemic control did not appear to be associated negative short-term outcomes. Glucose reduction in well-appearing ED patients may consume time and resources without conferring short- or long-term benefits. TRIAL REGISTRATION: Clinicaltrials.govNCT02478190.

Dose-Dependent Pulmonary Injury Following Nitrogen Dioxide Inhalation From Kinepak™ Detonation.

BACKGROUND: Nitrogen dioxide (NO2) is a pulmonary irritant produced as a byproduct of bacterial anaerobic metabolism of organic materials, and is also produced as a byproduct of explosive detonations. Significant NO2 exposure results in free-radical-induced pulmonary injury that may be delayed up to 3-30 h after exposure and can progress to acute respiratory distress syndrome (ARDS) and death. Here we present a case series of 3 patients with dose-dependent pulmonary injury consistent with NO2 inhalation following exposure to fumes from detonation of an ammonium nitrate/nitromethane (ANNM) explosive device. CASE REPORTS: Three individuals presented to the emergency department over the course of 16 h, beginning approximately 16 h after exposure to fumes from an ANNM explosive device. Patient 1, with the most significant exposure, developed ARDS necessitating intubation and mechanical ventilation. Patient 2 exhibited hypoxia and findings concerning for diffuse airway inflammation, but ultimately required only supplemental oxygen. Patient 3, with the least exposure, had imaging abnormalities but required no intervention. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Respiratory distress is a common presenting complaint to the emergency department. Because of the delayed presentation and the potential for progressive worsening of symptoms associated with NO2 exposure, it is important that emergency physicians be aware of the multiple potential means of exposure and consider this diagnosis in the proper clinical context. Patients with suspicion of NO2-related lung injury should undergo more extended observation than their initial clinical presentation may suggest.

The Effect of a Clinical Decision Support for Pending Laboratory Results at Emergency Department Discharge.

BACKGROUND: Health care systems often implement changes within the electronic health record (EHR) to improve patient safety and reduce medical errors. OBJECTIVE: To compare the proportion of emergency department (ED) encounters with laboratory tests resulting subsequent to patient discharge before and after a clinical decision support was implemented. METHODS: In 2015, our institution added an EHR dialogue when placing ED discharge orders, requiring providers to declare whether all laboratory results had been reviewed. To determine the effectiveness of this initiative, we searched the EHR to identify the proportion of ED encounters with laboratory tests resulting after discharge in pre- (January to June 2015) and post-intervention (January to June 2016) periods. RESULTS: There were 67,287 discharged patients during the study periods. In the pre- and post-intervention periods, respectively, 6.9% (95% confidence interval [CI] 6.7-7.2%) and 7.9% (95% CI 7.6-8.2%) of encounters had laboratory tests resulting after discharge, with an absolute difference of 0.9% (95% CI 0.5-1.3%). Of these patients with laboratory tests resulting after ED discharge, in 92% the provider inaccurately marked "yes" or "not applicable" to the EHR dialogue prompt. CONCLUSIONS: This workflow intervention was associated with an increase in the proportion of laboratory tests resulting after ED discharge; inaccurate answers to the EHR dialogue were pervasive. EHR workflow interventions do not always accomplish their intended goals, and their implementation should be considered thoughtfully.

Rescue Sedation When Treating Acute Agitation in the Emergency Department With Intramuscular Antipsychotics.

BACKGROUND: Rapid treatment of agitation in the emergency department (ED) is critical to avoid injury to patients and providers. Treatment with intramuscular antipsychotics is often utilized, but there is a paucity of comparative effectiveness evidence available. OBJECTIVE: The purpose of this investigation was to compare the effectiveness of droperidol, olanzapine, and haloperidol for treating agitation in the ED. METHODS: This was a retrospective observational study of adult patients who received intramuscular medication to treat agitation. Patients were classified based on the initial antipsychotic they received. The primary effectiveness outcome was the rate of additional sedation administered (rescue medication) within 1 h. Secondary outcomes included rescue sedation for the entire encounter and adverse events. RESULTS: There were 15,918 patients included (median age 37 years, 75% male). Rescue rates at 1 h were: 547/4947 for droperidol (11%, 95% confidence interval [CI] 10-12%), 988/8825 olanzapine (11%, 95% CI 10-12%), and 390/2146 for haloperidol (18%, 95% CI 17-20%). Rescue rates for the entire ED encounter were: 832/4947 for droperidol (17%, 95% CI 16-18%), 1665/8825 for olanzapine (19%, 95% CI 18-20%), and 560/2146 for haloperidol (26%, 95% CI 24-28%). Adverse events were uncommon: intubation (49, 0.3%), akathisia (7, 0.04%), dystonia (5, 0.03%), respiratory arrest (1, 0.006%), and torsades de pointes (0), with no significant differences between drugs. CONCLUSIONS: Olanzapine and droperidol lead to lower rates of rescue sedation at 1 h and overall, compared with haloperidol. There were no significant differences in major adverse events.

Unsuspected Critical Illness Among Emergency Department Patients Presenting for Acute Alcohol Intoxication.

STUDY OBJECTIVE: Emergency department (ED) visits for acute alcohol intoxication are common, but this population is at risk for decompensation and occult critical illness. The purpose of this study is to describe the incidence and predictors of unsuspected critical illness among patients with acute alcohol intoxication. METHODS: This was a retrospective observational study of ED patients from 2011 to 2016 with acute alcohol intoxication. The study cohort included patients presenting for alcohol intoxication, whose initial assessment was uncomplicated alcohol intoxication without any other active acute medical or traumatic complaints. The primary outcome was defined as the unanticipated subsequent use of critical care resources during the encounter or admission to an ICU. We investigated potential predictors for this outcome with generalized estimating equations. RESULTS: We identified 31,364 eligible patient encounters (median age 38 years; 71% men; median breath alcohol concentration 234 mg/dL); 325 encounters (1%) used critical care resources. The most common diagnoses per 1,000 ED encounters were acute hypoxic respiratory failure (3.1), alcohol withdrawal (1.7), sepsis or infection (1.1), and intracranial hemorrhage (1.0). Three patients sustained a cardiac arrest. Presence of the following had an increased adjusted odds ratio (aOR) of developing critical illness: hypoglycemia (aOR 9.2), hypotension (aOR 3.8), tachycardia (aOR 1.8), fever (aOR 7.6), hypoxia (aOR 3.8), hypothermia (aOR 4.2), and parenteral sedation (aOR 2.4). The initial blood alcohol concentration aOR was 1.0. CONCLUSION: Critical care resources were used for 1% of ED patients with alcohol intoxication who were initially assessed by physicians to have low risk. Abnormal vital signs, hypoglycemia, and chemical sedation were associated with increased odds of critical illness.

The Characteristics and Prevalence of Agitation in an Urban County Emergency Department.

STUDY OBJECTIVE: We seek to determine the characteristics and prevalence of agitation among patients in an urban county emergency department (ED). METHODS: This was a prospective observational study of ED patients at an urban Level I trauma center. All ED patients were screened during daily randomized 8-hour enrollment periods. Adult agitated patients, defined as having an altered mental status score greater than 1, were included. Trained research volunteers collected demographics and baseline data, including the presenting altered mental status score, use and type of restraints, and whether any initial sedative was given. The altered mental status score, vital signs, and any medications or treatments given were recorded every 5 minutes thereafter until the patient had an altered mental status score less than 1. Providers were asked to describe clinical events resulting in an intervention occurring during the patient course, including hypotension, vomiting, increased monitoring, use of supplemental oxygen or airway adjunct, or intubation. The provider also completed a checklist to determine the presence of delirium symptoms. RESULTS: A total of 43,838 patients were screened (45.1% women; median age 33 years; range 0 to 102 years). The prevalence of agitation was 2.6% (1,146/43,838; median altered mental status score 2). Of these patients, 84% (969/1,146) required physical restraint and 72% (829/1,146) required sedation with an intramuscular injection. Sedative agents were olanzapine in 39% of patients (442/1,146), droperidol in 20% (224/1,146), haloperidol in 20% (226/1,146), a benzodiazepine in 6% (68/1,146), and ketamine in 5% (52/1,146). Delirium characteristics were observed in 0.6% of patients (260/43,838), representing 23% of agitated patients in the ED. Clinical events were observed in 13% of agitated patients (114/866) without delirium symptoms and 26% (68/260) with delirium symptoms. Characteristics associated with a clinical event included delirium symptoms (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.2 to 2.4), a cause related to a drug other than alcohol (OR 1.7; 95% CI 1.1 to 2.9), or a nondrug-induced cause of agitation (OR 3.5; 95% CI 2.3 to 5.6). CONCLUSION: The prevalence of agitation in the ED was 2.6%. Agitated patients frequently required restraint and sedation, with significant rates of clinical events requiring intervention.