Effect of pharmacist-led task force to reduce opioid prescribing in the emergency department.

PURPOSE: Results of a study to determine the effect of a pharmacist-led opioid task force on emergency department (ED) opioid use and discharge prescriptions are presented. METHODS: An observational evaluation was conducted at a large tertiary care center (ED volume of 115,000 visits per year) to evaluate selected opioid use outcomes before and after implementation of an ED opioid reduction program by interdisciplinary task force of pharmacists, physicians, and nurses. Volumes of ED opioid orders and discharge prescriptions were evaluated over the entire 25-month study period and during designated 1-month preimplementation and postimplementation periods (January 2017 and January 2018). Opioid order trends were evaluated using linear regression analysis and further investigated with an interrupted time series analysis to determine the immediate and sustained effects of the program. RESULTS: From January 2017 to January 2018, ED opioid orders were reduced by 63.5% and discharge prescriptions by 55.8% from preimplementation levels: from 246.8 to 90.1 orders and from 85.3 to 37.7 prescriptions per 1,000 patient visits, respectively. Over the entire study period, there were significant decreases in both opioid orders (ß, -78.4; 95% confidence interval [CI], -88.0 to -68.9; R2, 0.93; p < 0.0001) and ED discharge prescriptions (ß, -24.4; 95% CI, -27.9 to -20.9; R2, 0.90; p < 0.001). The efforts of the task force had an immediate effect on opioid prescribing practices; results for effect sustainability were mixed. CONCLUSION: A clinical pharmacist-led opioid reduction program in the ED was demonstrated to have positive results, with a more than 50% reduction in both ED opioid orders and discharge prescriptions.

Emergency department waiting room: many requests, many insured and many primary care physician referrals.

BACKGROUND: Increase in waiting time often results in patients leaving the emergency department (ED) without being seen, ultimately decreasing patient satisfaction. We surveyed low-acuity patients in the ED waiting room to understand their preferences and expectations. METHODS: An IRB approved, 42-item survey was administered to 400 adult patients waiting in the ED waiting room for >15 min from April to August 2010. Demographics, visit reasons, triage and waiting room facility preferences were collected. RESULTS: The mean age of patients was 38.9 years (SD = 14.8), and 52.5% were females. About 53.8% of patients were employed, 79.4% had access to a primary care physician (PCP), and 17% did not have any medical insurance. The most common complaint was pain. A total of 44.4% respondents reported that they believed their problems were urgent and required immediate attention, prompting them to come to the ED, while 14.6% reported that they could not get a timely PCP appointment, and 42.9% were actually referred by their PCP to come to the ED. About 57.7% of patients considered leaving the ED if the waiting times were too long. The mean acceptable waiting time before leaving ED was 221 min (SD = 194; median 180 min, IQR 120-270). A total of 39.1% survey respondents reported being most comfortable being triaged by a physician. Respondents were least comfortable being triaged by residents. On analyzing waiting room expectations for the survey respondents, we found that 70% of the subjects wanted a better estimate of waiting time and 43.5% wanted better information on reasons for the long wait. CONCLUSION: Contrary to popular belief, at our ED a large proportion of low-acuity patients has a PCP and is medically insured. Providing patients with appropriate reasons for the wait, an accurate estimate of waiting time and creating separate areas to examine minor illness/injuries would increase patient satisfaction within our population subset.

Acute encephalopathy with concurrent respiratory and metabolic disturbances in first known parenteral human administration of flunixin meglumine and acepromazine maleate.

BACKGROUND: Flunexin is a nonsteroidal anti-inflammatory drug approved for veterinary use in horses and cattle. Acepromazine is a phenothiazine derivative used in horses, dogs, and cats. Human exposure to these substances is rare. CASE REPORT: We report a case of a human injection of two equine medications, flunixin and acepromazine, which resulted in altered mental status, respiratory alkalosis, gastrointestinal bleeding, and elevation of liver transaminases in a 43-year-old woman who worked as a horse trainer. The patient intentionally self-injected these medications and subsequently presented to the Emergency Department with altered mental status and lethargy. The patient required hospitalization for metabolic abnormalities, including respiratory alkalosis, and suffered a gastrointestinal bleed requiring blood transfusion. The patient ultimately recovered with supportive measures. We believe this to be the first case of concomitant injection of flunixin and acepromazine in a human. CONCLUSIONS: This report explains a case of parenteral administration of two equine medications and the subsequent complications in a patient that presented to the Emergency Department. Human exposure to veterinary medications cannot be predicted by their effect in animals due to variations in absorption, distribution, and metabolism. Physicians should be aware that individuals who work with animals may have access to large quantities of veterinary medicine. This case also exemplifies the challenges that Emergency Physicians face on a daily basis, and generates additional consideration for overdoses and intoxications from medications that are not considered commonplace in humans.