Pharmacist Presence Decreases Time to Prothrombin Complex Concentrate in Emergency Department Patients with Life-Threatening Bleeding and Urgent Procedures.

BACKGROUND: Reversal of anticoagulation with four-factor prothrombin complex concentrate (4F-PCC) is critical, yet the optimal timing to 4F-PCC administration and whether quicker administration improves hemostasis remains unknown. OBJECTIVE: The objective of this study was to determine if pharmacist presence is predictive of faster time to 4F-PCC. METHODS: This retrospective cohort study included patients receiving 4F-PCC for life-threatening bleeding or urgent procedure in the emergency department (ED) from 2014 to 2018. Patients with pharmacists at bedside (PharmD group) were compared with physician teams alone (control group). The primary outcome was time from ED presentation to 4F-PCC administration. RESULTS: Of 252 patients evaluated, 116 patients (46%) were included (n = 50 PharmD group; n = 66 control group). Most patients presented on warfarin (68.1%), and of the life-threatening bleeds (94%), intracranial hemorrhage was most common (67.2%). The median time to 4F-PCC administration was significantly shorter in the PharmD group (66.5 vs. 206.5 min, p < 0.001). Pharmacist at bedside was the only factor independently associated with reduction in time to 4F-PCC (ß coefficient -163.5 min, 95% confidence interval -249.4 to -77.7). Although there was no difference in hemostasis or mortality, patients in the PharmD group had a shorter intensive care unit length of stay (LOS) (2 vs. 5 days, p < 0.01) and hospital LOS (5.5 vs. 8 days, p = 0.02). CONCLUSION: A pharmacist at the bedside of patients who present to the ED with life-threatening bleeding or need for emergent procedure decreased time to 4F-PCC administration by 140 min, even after accounting for confounders. Faster time to 4F-PCC was associated with significantly shorter intensive care unit and hospital LOS.

Etomidate Use for Rapid Sequence Intubation Is Not Associated With Nosocomial Infection.

INTRODUCTION: Etomidate is commonly used for induction of anesthesia for rapid sequence intubation (RSI). It has little impact on hemodynamic status, making it a widely used agent. Due to the inhibition of cortisol production, etomidate causes adrenal suppression. The purpose of this study is to determine whether there is a correlation with etomidate use and the incidence of secondary infections. METHODS: This was a retrospective cohort of hospitalized patients who received either etomidate or control (ketamine, propofol, or no agent) for RSI. The primary endpoint was the incidence of secondary infections. Secondary outcomes included number of mechanical ventilator-free days within 28 days, 30-day mortality, length of hospital stay, and length of intensive care unit stay. RESULTS: A total of 434 patients were reviewed, of which 129 (29.7%) met the study criteria (n = 94 etomidate; n = 35 control). The incidence of secondary infection was numerically higher in the etomidate group compared with the control group, though this was not statistically significant (38.7% vs. 28.6%, p = 0.447). Also, though the secondary outcomes showed no statistically significant difference between the groups, the patients in the control group had a longer hospital stay (14.0 vs. 18.1, p = 0.20) and a longer ICU stay (11.0 vs. 14.1, p = 030). Furthermore, the etomidate group had a non-statistically significant higher incidence of bacteremia (8 vs. 0, p = 0.17). CONCLUSION: The use of etomidate was not associated with increased incidence of secondary infection. To fully understand the effects of etomidate use and its subsequent adrenal suppression, larger studies are needed.

COVID-19 infection characteristics and outcomes in a predominantly Latino community hospital.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has rapidly spread worldwide and claimed millions of lives. Several studies have attempted to understand the relationship between COVID-19 infection and health disparities. The aim of the current work was to evaluate the pre-admission health characteristics, symptomatology, diagnostic abnormalities, treatment measures and clinical outcomes of the community served by our institution, with a sub-analysis of our Hispanic community. Methods: This is a single-center, cross-sectional cohort study of patients with COVID-19 admitted from 15 March 2020 to 30 April 2020 to MacNeal Hospital. A retrospective chart review was performed including patients >18 years and a positive nasopharyngeal SARS-CoV-2 PCR. Demographical data, comorbidities, clinical data, treatment regimen, and patient outcomes were collected. Results: A total of 257 patients were included in the study of which 60.4% were identified as Hispanic. The median age at admission of Hispanic patients was significantly lower compared to non-Hispanic patients (56.6 vs. 65.7 years, p<0.01). Non-Hispanic patients had lower prevalence of hypertension, coronary artery disease, and chronic lung disease. Most common at presentation were shortness of breath (69.6%), cough (69.2%), and fever (64%). Hypertension was the most common comorbidity (53.6%). Approximately 89% of the patients received antibiotics, 40.4% hydroxy-chloroquine, 13.2% steroids, and 6% tocilizumab. Twenty six percent required mechanical ventilation (MV), and over half of them (56.7%) were Hispanic. The strongest factors associated with MV were smoking (OR 2.97, 95%CI 1.01-8.69), CRP >10 mg/dL (OR 4.53, 95%CI 1.49-13.38) and D-dimer >1.5 mcg/mL (OR 3.63, 95%CI 1.31-10.05). An oxygen saturation of >90% on room air on presentation was a protective factor when predicting intubation (OR 0.11, 95%CI 0.03-0.33). The overall 30-day mortality rate was 17.1% (n=44); 11.9% in the Hispanic group vs 26.3% in the non-Hispanic group (p<0.003). Conclusions: Our review of consecutive patients admitted with COVID-19 demonstrated that over half of patients were of Hispanic descent. Interestingly enough, despite being significantly younger and healthier, the need for mechanical ventilation in the Hispanic group was not significantly different compared to the non-Hispanic group. However, the Hispanic group had a lower mortality rate.