Impact of Education and Data Feedback on Antibiotic Prescribing for Urinary Tract Infections in the Emergency Department: An Interrupted Time-Series Analysis.

BACKGROUND: Urinary tract infections (UTIs) are often misdiagnosed or treated with exceedingly broad-spectrum antibiotics, leading to negative downstream effects. We aimed to implement antimicrobial stewardship (AS) strategies targeting UTI prescribing in the emergency department (ED). METHODS: We conducted a quasi-experimental prospective AS intervention outlining appropriate UTI diagnosis and management across 3 EDs, within an academic and 2 community hospitals, in North Carolina, United States. The study was divided into 3 phases: a baseline period and 2 intervention phases. Phase 1 included introduction of an ED-specific urine antibiogram and UTI guideline, education, and department-specific feedback on UTI diagnosis and antibiotic prescribing. Phase 2 included re-education and provider-specific feedback. Eligible patients included adults with an antibiotic prescription for UTI diagnosed in the ED from 13 November 2018 to 1 March 2021. Admitted patients were excluded. The primary outcome was guideline-concordant antibiotic use, assessed using an interrupted time-series regression analysis with 2-week intervals. RESULTS: Overall, 8742 distinct patients with 10 426 patient encounters were included. Ninety-two percent of all encounters (n = 9583) were diagnosed with cystitis and 8.1% with pyelonephritis (n = 843). There was an initial 15% increase in guideline-concordant antibiotic prescribing in phase 1 compared with the preintervention period (incidence rate ratio [IRR], 1.15; 95% confidence interval [CI], 1.03-1.29). A significant increase in guideline-concordant prescriptions was seen with every 2-week interval during phase 2 (IRR, 1.03; 95% CI, 1.01-1.04). CONCLUSIONS: This multifaceted AS intervention involving a guideline, education, and provider-specific feedback increased guideline-concordant antibiotic choices for treat-and-release patients in the ED.

Andexanet alfa and four-factor prothrombin complex concentrate for reversal of apixaban and rivaroxaban in patients diagnosed with intracranial hemorrhage.

Limited data exists regarding the clinical outcomes of andexanet alfa and four factor prothrombin complex concentrate (4F-PCC) for reversal of apixaban or rivaroxaban in the setting of intracranial hemorrhage (ICH). The objective of this study was to evaluate clinical outcomes of 4F-PCC and andexanet alfa for reversal of ICH associated with oral factor Xa inhibitors. This was a retrospective, single-center, case series evaluating hemostatic efficacy of patients receiving andexanet alfa) or 4F-PCC for reversal of apixaban or rivaroxaban after ICH. Secondary endpoints included in-hospital mortality, thrombotic complications, timing of reversal agents, intensive care unit and hospital length of stay, patient disposition, and 30-day readmission rate. During the study period, 21 patients received andexanet alfa and 35 received 4F-PCC. Hemostatic efficacy occurred in 64.7% of patients receiving andexanet alfa and 54.8% of receiving 4F-PCC. Thirty-day all-cause mortality was 45.2% for 4F-PCC and 30% for andexanet alfa. Thrombotic events were higher with 4F-PCC (31.4%) compared to andexanet alfa (14.3%). Median time from presentation to administration of reversal agent was 2.67 [1.75-4.13] hours with andexanet alfa and 1.73 [1.21-3.55] hours with 4F-PCC. Discharge to skilled nursing facilities and 30-day readmission were similar between groups. In this cohort, reversal with andexanet alfa and 4F-PCC differed in terms ofhemostatic efficacy and thrombotic events after ICH in patients anticoagulated with apixaban or rivaroxaban.

The role of subcutaneous ketorolac for pain management.

This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@ku.edu.

Simulation-Based Training to Improve Clinical Pharmacist Self-Efficacy in the Management of a Rapidly Decompensating Patient.

Background: The optimal training method to prepare pharmacists as an integral rapid response team or cardiopulmonary arrest responders is poorly described. This study assessed the utility of simulation-based training (SBT) as a training technique for clinical pharmacists. Objective: This study aimed to determine if attending SBT is associated with an improvement in self-efficacy. Methods: This single-center, prospective, interventional cohort study offered three simulations to clinical pharmacists over the course of seven months at a 957-bed quaternary care academic medical center. Pharmacists who participated in at least one simulation were categorized in the intervention group and were compared to pharmacists who did not attend a simulation. All participants were asked to complete a 19-question self-efficacy survey in the form of a 100-point scale, a 15-question multiple-choice knowledge assessment, and a perception survey in the form of 4-point Likert scale administered at baseline and following the conclusion of the SBT. Results: Forty-four clinical pharmacists participated; 20 in the intervention group and 24 in the control group. Median change in self-efficacy score improved significantly in the intervention group compared to the control group (14.3 vs 2.3, P = .009). Median change in perception score improved significantly (2 vs 0, P = .046). Knowledge score did not change significantly from baseline. Conclusion: Simulation-based training improved clinical pharmacist self-efficacy and perceptions in the care of rapidly decompensating patients. These findings support SBT as a viable modality of training clinical pharmacists for the management of rapidly decompensating patients.

Increasing Naloxone Prescribing in the Emergency Department Through Education and Electronic Medical Record Work-Aids.

BACKGROUND: Emergency department (ED) visits for opioid overdose continue to rise. Evidence-based harm reduction strategies for opioid use disorder (OUD), such as providing home naloxone, can save lives, but ED implementation remains challenging. METHODS: The researchers aimed to increase prescribing of naloxone to ED patients with OUD and opioid overdose by employing a model for improvement methodology, a multidisciplinary team, and high-reliability interventions. Monthly naloxone prescribing rates among discharged ED patients with opioid overdose and OUD-related diagnoses were tracked over time. Interventions included focused ED staff education on OUD and naloxone, and creation of electronic medical record (EMR)-based work-aids, including a naloxone Best Practice Advisory (BPA) and order set. Autoregressive interrupted time series was used to model the impact of these interventions on naloxone prescribing rates. The impact of education on ED staff confidence and perceived barriers to prescribing naloxone was measured using a published survey instrument. RESULTS: After adjusting for education events and temporal trends, ED naloxone BPA and order set implementation was associated with a significant immediate 21.1% increase in naloxone prescribing rates, which was sustained for one year. This corresponded to increased average monthly prescribing rates from 1.5% before any intervention to 28.7% afterward. ED staff education had no measurable impact on prescribing rates but was associated with increased nursing perceived importance and increased provider confidence in prescribing naloxone. CONCLUSIONS: A significant increase in naloxone prescribing rates was achieved after implementation of high-reliability EMR work-aids and staff education. Similar interventions may be key to wider ED staff engagement in harm reduction for patients with OUD.

Time to antivenom administration is not associated with total antivenom dose administered in a copperhead-predominant snakebite population.

OBJECTIVES: To prevent unnecessary antivenom administration in crotaline snakebite, observation for progression is recommended for the patient with minor envenomation whose condition is stable and not progressing. The objective of this study was to determine the association between the time from bite to initial antivenom administration (Time(AV)) and the total amount of antivenom administered (Total(AV)) and to determine what proportion of patients did not have progression of the envenomation syndrome and did not receive antivenom. METHODS: This was a retrospective chart review of patients presenting with crotaline snakebite within 24 hours from 2009 through 2012. Blinded dual-chart abstraction and strict data point definitions were used. Spearman correlation was used to determine the association between Time(AV) and Total(AV). A general linear model was used to examine this association using Time(AV) categorized to early and late administration, adjusted for likely confounders. Confounders included age, extremity involved, initial severity, and year of envenomation. RESULTS: Ninety-five eligible patients were analyzed with 45 (47%) males and a mean (±SD) age of 36.5 (±21.1) years. Eighty-five (89%) received antivenom, with a median Time(AV) of 3.3 hours (interquartile range [IQR] = 2.5 to 5.2 hours). The median Total(AV) was 10 vials (IQR = 6 to 14 vials). The univariate analysis showed a small but statistically significant decrease in Total(AV) given to patients treated greater than 6 hours from bite (r = -0.26, p = 0.015). The multivariate analysis resulted in no significant relation between early or late Time(AV) and Total(AV) (p = 0.10) after adjustment for confounders. Most minimal envenomation syndromes (80%, or 41 of 51) progressed to moderate grade envenomations. CONCLUSIONS: Time(AV) was not associated with Total(AV) when adjusted for likely confounders and supports current recommendations to observe for progression in minor envenomation. The majority of envenomations progressed, resulting in only a small proportion of patients not eventually receiving antivenom. The authors recommend observation in an environment where the patient can be adequately reassessed for progression of the envenomation.

Acute aortic emergencies--part 2: aortic dissections.

Patients with aortic disease are some of the highest acuity patients that emergency clinicians encounter. Dissection is the most common aortic catastrophe and involves separation of the aortic layers in a longitudinal fashion leading to diminished perfusion and systemic ischemia. Characteristics of pain, branch vessel involvement, and incidence lead to an understanding of patient presentation, morbidity, and mortality. Diagnosis, selection of diagnostic studies, the degree of preoperative ischemia, and risk of operative mortality can be accomplished using validated clinical decision tools. Emergency interventions are guided by the type of dissection according to the Stanford classification system. Medical management includes pain control and anti-impulse, antihypertensive therapy through vasodilatation and blockage of the sympathetic ß-response. The patient may then be evaluated for open surgical intervention, aortic fenestration, endovascularly placed stent grafts, or a combination possibly in a staged approach. Morbidity includes rupture, stroke, paraplegia, acute renal failure, bowel ischemia, and peripheral ischemia.

Management of first-trimester complications in the emergency department.

PURPOSE: The pharmacologic management and the nonpharmacologic management of first-trimester complications in the emergency department are reviewed. SUMMARY: The obstetric complications most commonly seen in early pregnancy (less than 20 weeks' gestation) include ectopic pregnancy, threatened and inevitable abortions, and incomplete, complete, and missed abortions. The treatment options for ectopic pregnancy include expectant management, medical management with methotrexate, and surgery. If patients have signs and symptoms of tubal rupture, surgery must be performed immediately. In other cases, the choice of management technique is based on the patient's clinical condition, factors related to the ectopic pregnancy, and the patient's preferences. Pharmacologic therapies for women with confirmed threatened abortion include human chorionic gonadotropin, progesterone, uterine muscle relaxants, and Rh immune globulin prophylaxis. Treatment goals for women whose condition has advanced to inevitable abortion include evacuating any retained products of conception, either with expectant (conservative) management or pharmacologic or surgical intervention. The best treatment option is often determined by the mother's clinical status at the time of presentation and her preference of management strategy. Management of complete abortion may not require any further intervention; however, it is often difficult to identify a complete versus incomplete abortion. Treatment options for complete, incomplete, and missed abortions include expectant, surgical, and medical management. CONCLUSION: Ectopic pregnancy, threatened and inevitable abortions, and incomplete, complete, and missed abortions are common complications during early pregnancy. Various medical and surgical treatment options are available for managing these complications, including expectant management, medical management, and surgery.