Extended-Release Naltrexone and Case Management for Treatment of Alcohol Use Disorder in the Emergency Department.

STUDY OBJECTIVE: To assess the feasibility of initiating treatment for alcohol use disorder with extended-release naltrexone and case management services in the emergency department (ED) and measure the intervention's impact on daily alcohol consumption and quality of life. METHODS: This is a 12-week prospective open-label single-arm study of a multimodal treatment for alcohol use disorder consisting of monthly extended-release naltrexone injections and case management services initiated at an urban academic ED. Participants were actively drinking adult patients in ED with known or suspected alcohol use disorder and an AUDIT-C score more than 4. The main feasibility outcomes included the rates of participant enrollment, retention in the study, and continuing treatment after study completion. Efficacy outcomes were the change in daily alcohol consumption (drinks per day; 14 g ethanol per drink), measured by a 14-day timeline followback, and the change in quality of life measured with a single-item Kemp quality of life scale. RESULTS: One hundred seventy-nine patients were approached, and 32 were enrolled (18%). Of the 32 enrolled patients, 25 (78%) completed all visits, and 22 (69%) continued naltrexone after the trial. The mean baseline daily alcohol consumption was 7.6 drinks per day (interquartile range, 4.5, 13.4), and the mean quality of life was 3.6 (SD 1.7) on a 7-point scale. The median daily alcohol consumption change was -7.5 drinks per day (Hodges-Lehmann 95% confidence interval -8.6, -5.9). The mean quality of life change was 1.2 points (95% confidence interval 0.5, 1.9; P<.01). CONCLUSION: We found that initiation of treatment of alcohol use disorder with extended-release naltrexone and case management is feasible in an ED setting and observed significant reductions in drinking with improved quality of life in the short term. Multicenter randomized controlled trials are needed to further validate these findings.

Treatment of Toxin-Related Status Epilepticus With Levetiracetam, Fosphenytoin, or Valproate in Patients Enrolled in the Established Status Epilepticus Treatment Trial.

STUDY OBJECTIVE: We describe a subset of patients with toxin-related precipitants of seizures/status epilepticus enrolled in the Established Status Epilepticus Treatment Trial (ESETT). METHODS: The ESETT was a prospective, double-blinded, adaptive trial evaluating levetiracetam, valproate, and fosphenytoin as second-line agents in benzodiazepine-refractory status epilepticus in adults and children. The primary outcome was the absence of seizures and improvement in the level of consciousness 1 hour after study drug administration. In this post hoc analysis, the safety and efficacy of second-line agents in a subset of patients with toxin-related seizures are described. RESULTS: A total of 249 adults and 229 children were enrolled in the ESETT. Toxin-related seizures occurred in 29 (11.6%) adults and 1 child (0.4%). In adults, men were more likely to have toxin-related seizures than women (25 of 145, 17.2% versus 4 of 104, 3.9%). The most common toxin-related precipitants were alcohol withdrawal and cocaine, 11(37%) of 30 patients each. Cocaine was used with other substances by most patients 10 (91%) of 11, most commonly with an opioid 7 (64%) of 11. For alcohol withdrawal-related seizures, treatment successes with levetiracetam, valproate, and fosphenytoin were 3 (100%) of 3, 3 (50%) of 6, and 1 (50%) of 2, respectively. For cocaine-related seizures, treatment success was 1 (14%) of 7 for levetiracetam, 0 (0%) of 1 for valproate, and 1 (33%) of 3 for fosphenytoin. One patient who used cocaine and an opioid received fosphenytoin and developed life-threatening hypotension. CONCLUSION: In the ESETT, approximately 1 in 10 adult patients with status epilepticus presented with a toxin-related seizure. Alcohol withdrawal and cocaine/opioid use were the most common toxin-related precipitants. Toxin-related benzodiazepine-refractory status epilepticus was successfully treated with a single dose of second-line antiseizure medication in 42% of the patients.

Use of Capsaicin Cream in Cannabinoid Hyperemesis Syndrome in Patients Presenting to the Emergency Department.

BACKGROUND: Cannabinoid hyperemesis syndrome (CHS) is characterized by cyclical nausea, vomiting, and abdominal pain often relieved with hot showers. Patients with CHS are usually long-term cannabis smokers whose symptoms are not relieved by antiemetics. The use of topical capsaicin has been recently reported as an adjunctive therapy in the emergency department (ED). OBJECTIVE: To describe the use of capsaicin cream in patients presenting to the ED with suspected CHS. METHODS: We performed a retrospective review of patients with suspected CHS receiving capsaicin in an ED from July 2014 to October 2018. We report data on demographics, cannabis consumption, hot showers use, length of stay, concurrent treatments, pain scores, and adverse events. RESULTS: There were 57 patients who received capsaicin cream for suspected CHS. Nearly all patients received antiemetics (98%), whereas 47% of patients received an opioid. Antiemetics were typically administered first (median, 1.6 hours; interquartile range [IQR], 0.9-2.4]), followed by an opioid (median, 1.8 hours [IQR, 1-3.75]), followed by capsaicin cream (median 4 hours [IQR, 2.7-5.2]). The overall precapsaicin pain score was 8 (IQR, 2-9), decreasing to 5.5 (IQR, 0-8). Around 42% of patients received no further symptomatic therapy after capsaicin. No adverse drug events to capsaicin were reported. CONCLUSION AND RELEVANCE: This is the largest retrospective study describing capsaicin cream use in suspected CHS patients with a focus on abdominal pain relief. Capsaicin treatment was associated with a modest pain score reduction. Application of these findings may help providers in identifying more effective therapies to provide symptomatic relief for CHS patients.

Intermittent Versus Continuous Infusion Dosing of Intravenous Proton Pump Inhibitors for Upper Gastrointestinal Bleeding.

BACKGROUND: Proton pump inhibitor (PPI) continuous infusions or intermittent boluses are used for the treatment of upper gastrointestinal bleeding (UGIB). Intermittent boluses are easier to give and are of lower cost without affecting clinical outcomes. OBJECTIVE: To compare the rate of rebleeding between intermittent bolus and continuous infusion PPI therapy. METHODS: We performed a retrospective, multicenter review of patients with UGIB receiving either continuous or intermittent PPI therapy. During the study period, due to drug and supply shortages, each institution implemented policies preferring intermittent PPI bolus therapy. We performed bivariate and multivariable comparisons of the 2 treatment strategies, with the primary outcome of interest being incidence of rebleeding. Additional variables of interest included intensive care unit (ICU) and hospital lengths of stay, discharge disposition, and in-hospital mortality. RESULTS: Compared with intermittent bolus dosing (n = 209), patients receiving continuous infusion PPI (n = 237) were associated with a higher rate of rebleeding (33.8% vs 23.0%; P = 0.012); however, no difference was detected in multivariable analysis: adjusted odds ratio, 1.50 (95% confidence interval, 0.91-2.50). There was no difference in median hospital or ICU length of stay, discharge disposition, or in-hospital mortality. Correlatively, patients receiving continuous infusion therapy were more likely to have liver disease (29.1% vs 20.1%; P = 0.028), alcohol use disorder (28.3% vs 16.3.%; P = 0.003), history of lower gastrointestinal bleeding (6.4% vs 1.9%; P = 0.021), variceal bleeding (6.3 vs 2.4%, P = 0.045), and be admitted to the ICU (65.0% vs 32.5%, P = 0.00). CONCLUSIONS: Introduction of intermittent PPI bolus UGIB treatment via change in hospital policy was not associated with higher rates of rebleeding. However, continuous PPI therapy may have been perceived as more effective as it was used more commonly in high-risk patients.

Haloperidol Versus Ziprasidone With Concomitant Medications and Other Predictors of Physical Restraint Duration in the Emergency Department.

BACKGROUND: Patients with severe agitation are frequently encountered in the emergency department (ED). At times, these patients are physically restrained and given calming medications; however, little is known about the effects of medications and other predictors on restraint duration. OBJECTIVE: Our aim was to compare restraint duration when haloperidol or ziprasidone was used as the primary antipsychotic with or without concomitant medications, and to identify predictors of restraint duration. METHODS: We performed a review of a retrospective cohort of physically restrained ED patients between January 1, 2013 and November 30, 2017. An unadjusted analysis and adjusted linear regression model were used to evaluate the effect of antipsychotic choice on restraint duration, controlling for sex, age, race, homelessness, arrival in restraints, re-restraint during visit, concomitant medications (i.e., benzodiazepines or anticholinergics), additional medications given during restraint, time of day, and patient disposition. RESULTS: In 386 patients (319 haloperidol, 67 ziprasidone), the average restraint duration was 2.4 h (95% confidence interval [CI] 2.2 to 2.6 h). There were no differences in physical restraint times between ziprasidone and haloperidol groups in the unadjusted (mean difference 0.12 h; 95% CI -0.42 to 0.66 h) or adjusted analyses (-12.7%; 95% CI -33.9% to 8.6%). Haloperidol given with diphenhydramine alone was associated with decreased restraint duration (-30.8%; 95% CI -50.6% to -11.1%) The largest association with restraint duration was administration of additional sedating medications during restraint, prolonging restraint by 62% (95% CI 27.1% to 96.9%). In addition, compared with White patients, Black patients spent significantly more time restrained (mean difference 33.9%; 95% CI 9.0% to 58.9%). CONCLUSIONS: Restraint duration of agitated ED patients was similar when haloperidol or ziprasidone was used as the primary antipsychotic. However, race and additional medications given during restraint were significantly associated with restraint duration.

Clinical pharmacy services in the emergency department.

The emergency department (ED) is a fast-paced, high-risk, and often overburdened work environment. Formal policy statements from several notable organizations, including the American College of Emergency Physicians (ACEP) and the American Society of Health-System Pharmacists (ASHP), have recognized the importance of clinical pharmacists in the emergency medicine (EM) setting. EM clinical pharmacists work alongside emergency physicians and nurses at the bedside to optimize pharmacotherapy, improve patient safety, increase efficiency and cost-effectiveness of care, facilitate antibiotic stewardship, educate patients and clinicians, and contribute to scholarly efforts. This paper examines the history of EM clinical pharmacists and associated training programs, the diverse responsibilities and roles of EM clinical pharmacists, their impact on clinical and financial outcomes, and proposes a conceptual model for EM clinical pharmacist integration into ED patient care. Finally, barriers to implementing EM clinical pharmacy programs and limitations are considered.

Ketamine procedural sedation in the emergency department of an urban tertiary hospital in Dar es Salaam, Tanzania.

STUDY OBJECTIVE: We describe ketamine procedural sedations and associated adverse events in low-acuity and high-acuity patients in a resource-limited ED. METHODS: This was a prospective observational study of ketamine procedural sedations at the Emergency Medical Department at the Muhimbili National Hospital in Dar es Salaam, Tanzania. We observed consecutive procedural sedations and recorded patient demographics, medications, vital signs, pulse oximetry, capnography and a priori defined adverse events (using standard definitions in emergency medicine sedation guidelines). All treatment decisions were at the discretion of the treating providers who were blinded to study measurements to simulate usual care. Data collection was unblinded if predefined safety parameters were met. For all significant adverse and unblinding events, ketamine causality was determined via review protocol. Additionally, providers and patients were assessed for sedation satisfaction. RESULTS: We observed 54 children (median 3 years, range 11 days-15 years) and 45 adults (median 33 years, range 18-79 years). The most common indications for ketamine were burn management in children (55.6%) and orthopaedic procedures in adults (68.9%). Minor adverse events included nausea/vomiting (12%), recovery excitation (11%) and one case of transient hypertension. There were nine (9%) patients who had decreased saturation readings (SpO2 ≤92%). There were three deaths, all in severely injured patients. After review protocol, none of the desaturations or patient deaths were thought to be caused by ketamine. No patient experienced ketamine-related laryngospasm, apnoea or permanent complications. Overall, ketamine was well tolerated and resulted in high patient and provider satisfaction. CONCLUSION: In this series of ketamine sedations in an urban, resource-limited ED, there were no serious adverse events attributable to ketamine.

Simple text-messaging intervention is associated with improved door-to-needle times for acute ischemic stroke.

BACKGROUND AND PURPOSE: Timely administration of intravenous tissue-type plasminogen activator (IV tPA) is associated with improved outcomes for acute ischemic stroke; yet, developing processes to consistently provide prompt treatment remains a challenge. We developed and evaluated a simple quality improvement intervention designed to improve door-to-needle (DTN) times for resident-led Code Stroke teams at an academic medical center. METHODS: We evaluated a simple text-messaging based intervention with real-time feedback to improve DTN times for intravenous tissue-type plasminogen activator. We used the rank-sum test and linear regression to evaluate for a change in DTN times that was temporally associated with the rollout of the intervention. RESULTS: A total of 202 patients received intravenous tissue-type plasminogen activator; 94 preintervention and 108 postintervention. The median DTN time was significantly lower in the postintervention period (56 minutes [interquartile range 44-71] versus 82 minutes [IQR 68-103], P<0.0001) and a significantly higher proportion of patients were treated within 60 minutes (61% versus 16%, P<0.001). CONCLUSIONS: A simple real-time text-messaging intervention was associated with a significant improvements in DTN times for acute ischemic stroke.

Genetic Predictive Factors for Nonsusceptible Phenotypes and Multidrug Resistance in Expanded-Spectrum Cephalosporin-Resistant Uropathogenic Escherichia coli from a Multicenter Cohort: Insights into the Phenotypic and Genetic Basis of Coresistance.

Antimicrobial resistance in urinary tract infections (UTIs) is a major public health concern. This study aims to characterize the phenotypic and genetic basis of multidrug resistance (MDR) among expanded-spectrum cephalosporin-resistant (ESCR) uropathogenic Escherichia coli (UPEC) causing UTIs in California patient populations. Between February and October 2019, 577 ESCR UPEC isolates were collected from patients at 6 clinical laboratory sites across California. Lineage and antibiotic resistance genes were determined by analysis of whole-genome sequence data. The lineages ST131, ST1193, ST648, and ST69 were predominant, representing 46%, 5.5%, 4.5%, and 4.5% of the collection, respectively. Overall, 527 (91%) isolates had an expanded-spectrum ß-lactamase (ESBL) phenotype, with blaCTX-M-15, blaCTX-M-27, blaCTX-M-55, and blaCTX-M-14 being the most prevalent ESBL genes. In the 50 non-ESBL phenotype isolates, 40 (62%) contained blaCMY-2, which was the predominant plasmid-mediated AmpC (pAmpC) gene. Narrow-spectrum ß-lactamases, blaTEM-1B and blaOXA-1, were also found in 44.9% and 32.1% of isolates, respectively. Among ESCR UPEC isolates, isolates with an ESBL phenotype had a 1.7-times-greater likelihood of being MDR than non-ESBL phenotype isolates (P < 0.001). The cooccurrence of blaCTX-M-15, blaOXA-1, and aac(6')-Ib-cr within ESCR UPEC isolates was strongly correlated. Cooccurrence of blaCTX-M-15, blaOXA-1, and aac(6')-Ib-cr was associated with an increased risk of nonsusceptibility to piperacillin-tazobactam, cefepime, fluoroquinolones, and amikacin as well as MDR. Multivariate regression revealed the presence of blaCTX-M-55, blaTEM-1B, and the ST131 genotype as predictors of MDR. IMPORTANCE The rising incidence of resistance to expanded-spectrum cephalosporins among Escherichia coli strains, the most common cause of UTIs, is threatening our ability to successfully empirically treat these infections. ESCR E. coli strains are often MDR; therefore, UTI caused by these organisms often leads to treatment failure, increased length of hospital stay, and severe complications (D. G. Mark, Y.-Y. Hung, Z. Salim, N. J. Tarlton, et al., Ann Emerg Med 78:357-369, 2021, https://doi.org/10.1016/j.annemergmed.2021.01.003). Here, we performed an in-depth analysis of genetic factors of ESCR E. coli associated with coresistance and MDR. Such knowledge is critical to advance UTI diagnosis, treatment, and antibiotic stewardship.

Brief Summary of Potential SARS-CoV-2 Prophylactic and Treatment Drugs in the Emergency Department.

As of March 30th, 2020 there were 161,807 total cases and 2,953 total deaths of SARS-CoV-2 in the United States, with the number of cases expected to rise. Other than supportive care, there are no SARS-CoV-2 specific treatments available for patients discharged from the emergency department (ED) or those admitted to the hospital. In addition, there are no vaccines available to protect our at-risk healthcare workers. The National Institutes of Health is conducting a Phase 1 clinical trial to evaluate for a potential vaccine and the recipients have started to receive the investigational vaccine.2 We present a brief overview of the potential prophylactic and treatment agents under investigation, some which could be initiated in the ED if proven effective.

Association Between Methamphetamine Use and Psychiatric Hospitalization, Chemical Restraint, and Emergency Department Length of Stay.

OBJECTIVES: Methamphetamine intoxication is an increasing cause of emergency department (ED) visits in the United States, particularly in the west. In San Francisco, California, 47% of patients visiting psychiatric emergency services are intoxicated with methamphetamine. Such patients often visit the ED due to acute psychiatric symptoms, yet ED-based research investigating the outcomes and resource utilization of these visits is limited. METHODS: We examined a retrospective cohort of ED patients requiring ED-based psychiatric consultation from June 2017 to July 2018. We evaluated the association between methamphetamine visits and need for chemical restraint, psychiatric hospitalization, and length of stay (LOS). RESULTS: We identified 2,087 ED visits with psychiatric consults. Based on urine toxicology results and discharge diagnosis, 403 visits involved methamphetamine with or without other drugs, 480 involved other drugs without methamphetamine, and 1,204 had no evidence of drug use. Methamphetamine visits were associated with increased odds of chemical restraint compared to visits without drug use (adjusted odds ratio [AOR] = 3.2, 95% CI = 2.1 to 5.2, p < 0.001), but not other drug visits (AOR = 1.2, 95% CI = 0.8 to 1.9, p = 0.4). Methamphetamine visits had lower odds of psychiatric hospitalization than other drug visits (AOR = 0.62, 95% CI = 0.41 to 0.95, p = 0.03) and longer adjusted LOS than visits without drug use (+4.3 hours, 95% CI = 4.1 to 8.3 hours, p < 0.001) but not other drug visits (+1.5 hours, 95% CI = -0.6 to 3.7 hours, p = 0.2). CONCLUSIONS: Methamphetamine ED visits were associated with increased odds of needing chemical restraint and of an increased ED LOS but not with psychiatric inpatient admission. These results indicate an opportunity to improve the efficiency of ED care for these patients.

Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: A Randomized Quality Improvement Study.

Importance: Prescription opioids play a significant role in the ongoing opioid crisis. Guidelines and physician education have had mixed success in curbing opioid prescriptions, highlighting the need for other tools that can change prescriber behavior, including nudges based in behavioral economics. Objective: To determine whether and to what extent changes in the default settings in the electronic medical record (EMR) are associated with opioid prescriptions for patients discharged from emergency departments (EDs). Design, Setting, and Participants: This quality improvement study randomly altered, during a series of five 4-week blocks, the prepopulated dispense quantities of discharge prescriptions for commonly prescribed opioids at 2 large, urban EDs. These changes were made without announcement, and prescribers were not informed of the study itself. Participants included all health care professionals (physicians, nurse practitioners, and physician assistants) working clinically in either of the 2 EDs. Data were collected from November 28, 2016, through July 9, 2017, and analyzed from July 16, 2017, through May 14, 2018. Interventions: Default quantities for opioids were changed from status quo quantities of 12 and 20 tablets to null, 5, 10, and 15 tablets according to a block randomization scheme. Regardless of the default quantity, each health care professional decided for whom to prescribe opioids and could modify the quantity prescribed without restriction. Main Outcomes and Measures: The primary outcome was the number of tablets of opioid-containing medications prescribed under each default setting. Results: A total of 104 health care professionals wrote 4320 prescriptions for opioids during the study period. Using linear regression, an increase of 0.19 tablets prescribed (95% CI, 0.15-0.22) was found for each tablet increase in default quantity. When evaluating each of the 15 pairwise comparisons of default quantities (eg, 5 vs 15 tablets), a lower default was associated with a lower number of pills prescribed in more than half (8 of the 15) of the pairwise comparisons; there was a higher quantity in 1 and no difference in 6 comparisons. Conclusions and Relevance: These findings suggest that default settings in the EMR may influence the quantity of opioids prescribed by health care professionals. This low-cost, easily implementable, EMR-based intervention could have far-reaching implications for opioid prescribing and could be used as a tool to help combat the opioid epidemic. Trial Registration: ClinicalTrials.gov identifier: NCT04155229.

Evaluation of the Impact of a Multimodel Intervention on Prescribing Patterns of Sedative-Hypnotics in a Behavioral Health System.

OBJECTIVE: To describe the effect of a multimodal intervention targeting chronic benzodiazepine and sedative-hypnotic prescriptions in a large behavioral health system. METHODS: This retrospective study analyzed chronic sedative-hypnotic prescription rates in patients seeking mental health services in a large behavioral health system. The multimodal intervention consisted of provider education, coordination of care with all providers involved in patient care, and guideline development and implementation for safe prescribing of sedative-hypnotics. Three time periods were analyzed: preintervention (October 2013-December 2013), 12-month assessment (October 2014-December 2014), and 24-month assessment (October 2015-December 2015). The primary outcome of the study was the change in frequency of chronic (≥ 60 days) sedative-hypnotic prescriptions received before and after the multimodal intervention. The secondary outcome included the change in prescription rates in a priori-defined cohorts: patients on methadone maintenance therapy and patients ≥ 60 years of age. RESULTS: There were 32,944 prescriptions during the study period. The rate of chronic sedative-hypnotic prescriptions decreased from 1,764 (15.3%) to 1,634 (14.9%) to 1,018 (9.8%) between the 3 assessment periods, respectively. A significant decrease occurred between the preintervention period and 24-month assessment (5.5%, P < .0001) and between the 12-month assessment and the 24-month assessment (5.1%, P < .0001). In the elderly, prescription rates decreased significantly between the preintervention period and the 24-month assessment (3.6%, P < .0001) and the 12-month and 24-month assessments (3.2%, P = .0001). In patients in methadone maintenance programs, rates of concomitant chronic sedative-hypnotic prescriptions decreased significantly between all assessment periods: preintervention and 12-month assessment (8.2%, P = .001), 12-month and 24-month assessment (6.3%, P = .002), and preintervention and 24-month assessment (14.5%, P < .0001). Additionally, prescription rates increased significantly for antidepressants (4.1%, P < .05), hydroxyzine (1.1%, P = .01), buspirone (2.1%, P < .05), gabapentin (6.3%, P < .05), and melatonin agonists (0.3%, P < .05) between the preintervention and 24-month assessment periods. CONCLUSIONS: Implementation of a multimodal intervention led to a significant decrease in rates of chronic sedative-hypnotic prescriptions in a large behavioral health system.

Effect of a single dose of i.v. ondansetron on QTc interval in emergency department patients.

PURPOSE: Results of a study to determine whether i.v. administration of a single dose of 4 mg of ondansetron was associated with QT interval prolongation in emergency department (ED) patients are reported. METHODS: In a prospective observational study conducted at an urban academic medical center ED, a convenience sample of adult ED patients treated with ondansetron 4 mg i.v. were enrolled. A 12-lead electrocardiogram (ECG) was obtained immediately before and 5 minutes after ondansetron administration. Measurements of heart rate-corrected QT interval (QTc measurements) provided by ECG machines were evaluated. An electrophysiologist analyzed all ECGs for adverse electrical events and verified the accuracy of QTc values. The primary objective was to measure the QTc change from baseline after ondansetron administration. The secondary objective was to describe adverse electrical cardiac events. Interactions between ondansetron and patients' home medications or ED-provided medications were analyzed. RESULTS: Among patients included in the data analysis (n = 20), ondansetron administration was associated with a mean QTc increase of 16.2 msec (95% confidence interval, 4.2-28.2 msec; p = 0.01) and a median increase of 12 msec (interquartile range, 5.5-18.0 msec; p < 0.01). One patient had a significant cardiac event (pulseless electrical activity) that was likely unrelated to ondansetron use. The home medications of 9 patients (42.9%) were deemed to pose a risk of torsades de pointes, and 17 major QT-prolonging drug-drug interactions were identified. CONCLUSION: Significant QTc prolongation occurred in ED patients receiving a single 4-mg i.v. dose of ondansetron. None of the patients had an ondansetron-related cardiac adverse event.

Root Cause Analysis of Ambulatory Adverse Drug Events That Present to the Emergency Department.

BACKGROUND: Adverse drug events (ADEs) among patients self-administering medications in home/community settings are a common cause of emergency department (ED) visits, but the causes of these ambulatory ADEs remain unclear. Root cause analysis, rarely applied in outpatient settings, may reveal the underlying factors that contribute to adverse events. STUDY OBJECTIVES: To elicit patient and provider perspectives on ambulatory ADEs and apply root cause analysis methodology to identify cross-cutting themes among these events. METHODS: Emergency department clinical pharmacists screened, identified, and enrolled a convenience sample of adult patients 18 years or older who presented to a single, urban, academic ED with symptoms or diagnoses consistent with suspected ADEs. Semistructured phone interviews were conducted with the patients and their providers. We conducted a qualitative analysis. We applied a prespecified version of the injury prevention framework (deductive coding), identifying themes relating to the agent (drug), host (patient), and environment (social and health systems). These themes were used to construct a root cause analysis for each ADE. RESULTS: From 18 interviews overall, we identified the following themes within the injury prevention framework. Agent factors included high-risk drugs, narrow therapeutic indices, and uncommon severe effects. Host factors included patient capacity or understanding of how to use medications, awareness of side effects, mistrust of the medical system, patients with multiple comorbidities, difficult risk-benefit assessments, and high health-care users. Environmental factors included lack of social support, and health systems issues included access to care, encompassing medication availability, access to specialists, and a lack of continuity and communication among prescribing physicians. Root cause analysis revealed multiple underlying factors relating to agent, host, and environment for each event. CONCLUSION: Patient and physician perspectives can inform a root cause analysis of ambulatory ADEs. Such methodology may be applied to understand the factors that contribute to ambulatory ADEs and serve as the formative work for future interventions improving home/community medication use.

Prochlorperazine-Induced Hemidystonia Mimicking Acute Stroke.

Prochlorperazine is frequently used in the treatment of refractory nausea and migraines. Known side effects include extrapyramidal symptoms such as akathisia and dystonia. We report a pregnant patient taking prochlorperazine for hyperemesis gravidarum who developed hemidystonia, which triggered an acute code stroke response from prehospital, emergency medicine and neurology providers. We suspect this report to be the first case of prochlorperazine-induced hemidystonia as a stroke mimic.